This profile unearths the gross violation of women’s maternal health rights in Madhya Pradesh, one of the most populas states in India and together with Bihar, Orissa, Rajasthan and Utter Pradesh accounting for 50% of the India’s projected population of 1.0 Billion by the year 2012 (10th Five Year Plan, Planning Commission, Government of India). This reveals that the Government of Madhya Pradesh spends only Rs. 9 per women per annum to provide maternal health care and unfortunately the society never registered its reaction towards state’s gross negligence. Problems do not end here. The state has highest rate malnutrition, particularly amongst among children. Fifty five percent of children below 3 years are under weight, 51% are stunted, 20% are wasted and 75% of them are anemic. Maternal Mortality rate in MP is one of the highest in the country, 498 per 100,000 live births, IMR is high too 87/1000 live births (NFHS II, 1998-99; Registrar General of India, 1999). But the Madhya Pradesh Family Welfare Program Evaluation Survey (MPFWPES) 2003 conducted by the Government o Madhya Pradesh reveals that the risk of death due to complications of pregnancy and childbirth in the rural areas of the state was 763 maternal deaths for every 100,000 live births. The reach of health and nutrition services is far from satisfactory, with only 22% of the children having received all vaccinations before 12 months and only one fourth of the children 6-35 Months having received one dose of Vitamin-A. The present paper discusses the reality of health services, social negligence and it’s interrelations with the larger developmental processes in the state of Madhya Pradesh.

Background 

If you really want to experience at the deepest levels of your soul what it means to be a part of the neglected section of society with no access to basic health services, you should visit Balwadi health centre in tribal dominated Sendhwa development block in Badwani district of Madhya Pradesh. This health centre `caters’ to around 30 villages inhabited by about 21,000 people. Since there is no doctor here, a compounder looks after the center since last three years and there is no availability of medicines and equipments for 9 months in a year. It is only natural that in this circle, 13 children died due to malnutrition related diseases [A study done by the Sendhwa based Adiwasi Mukti Sanghthan, a people’s organization fighting for the tribal rights, 2005.] and 34 women died over the last one year during childbirth obviously due to lack of adequate socio-psychological-medical services. This scene is not confined only to this Balwadi, but it plagues entire Madhya Pradesh, where several people have to compromise on their lives due to severe violations of basic health rights.

If Sendhwa shocks you, you would certainly not like to visit Reethi. When the policy makers in State were in throes of hot debate over the change in the political leadership, a sad incident was unfolding in Reethi development block of Katni district during the month of October. At least 20 out of 32 infants (born during month) died in the solitary hospital providing health services to 56 panchayats in this block [Case study documented during the group discussion with the local social developmental organizations.]. There is no gynecologist, no surgery department, equipments, emergency services or medicines available in the block hospital. Only one differently abled lady doctor continues her struggle all alone waiting for a miracle (Sandip Naik, 2005). It is difficult to provide maternal health care, when a single gynecologist has to cover a population of 1.20 Lakhs.

It is a bitter truth that Governments are still not constitutionally bound to provide health services to the society, as the right to health is a matter of directive principles and the state is not bound to follow directions. In this context, most marginalized sections of the society, specifically women, suffer most and pay with their lives highlighting negligence and insensitivity of the government. While governments put some basic efforts, there is no political will or power to sustain these efforts or make them successful.

In fact, people not only face diseases, but also are caught in the net of attractive Government schemes mostly confined to paperwork. The harsh reality is that over 3.21 lakh people are still dying of curable diseases in the state, and 38 women die every day during delivery. According to available figures 14000 women die due to maternal related causes and most of the deaths can be prevented, if taken seriously. This puts Madhya Pradesh as one of the top three states with highest number of maternal deaths in country. Although, this data has been challenged by different studies, even the Madhya Pradesh Family Welfare Program Evaluation Survey (MPFWPES) 2003 carried out by State Government, covering 25 percent of the rural population of the state, does not paint too rosy a picture. This survey provides the estimates of maternal mortality ratio for rural areas of Madhya Pradesh, minus Chattisgarh. According to the MPFWPES-2003, the risk of death due to complications of pregnancy and childbirth in the rural areas of the state was 763 maternal deaths for every 100,000 live births. The estimates provided by the Rapid House Hold Survey suggest a maternal mortality ratio of 597 maternal deaths for every 100,000 live births for the year 1999. Unfortunately, all these figures present a bleak picture that the women of Madhya Pradesh carry both a substantially high risk of death due to complications of pregnancy, delivery and in post partum period and a substantially high life time risk of death due to reproduction associated consequences [Obstetric Care in Central India, Ed. - Alok Ranjan & R William Stones, Pg-25 to 60.]. The per capita public expenditure on rural areas amount to less than a third of that spent per capita in urban areas. IMR in rural areas is significantly higher than urban areas. ANC services are almost two and half times more in urban areas as compared to rural. More than 86% of deliveries in rural areas were at home as compared to 50% in urban areas. 61% of the deliveries in urban areas were assisted by doctors or trained personnel as compared to 21% in rural areas. There are about 5000 qualified doctors (including 1500 ISM&H practitioners) in government service compared to 20,000 in the private sector. The DoHFW’s 16,900 MPW (male) and ANMs could be contrasted with RMPs and Dais (50,000 each) offering health services at the household level, particularly in rural areas [The Health Sector in MP, Situation analysis, June 2002, HLSP Consulting Ltd., MSG.].

About Maternal Mortality!

Many times we encounter the data of Maternal Mortality or Maternal Deaths. It is really tough to make sensitive efforts to define these terms in a socio-political manner rather than in medical terminology. The causes of deaths during or after the pregnancy period or at the delivery time has traditionally been classified in two sections - Direct and Indirect. In Direct causes pregnancy causes death and in Indirect causes where an underlying disease is aggravated by pregnancy [Birth Counts: Statistics of Pregnancy and Child Birth – A. Macfarlane and M. Mugford, 1984.]. It is worth mentioning fact that in the past a number of indirect causes of maternal mortality were excluded from the estimation processes before the release of 9th revision of the International Classification of Diseases, Disability and Causes of Death (ICD) prepared by the World Health Organization. After certain debates and studies, the ninth revision of ICD includes the direct and Indirect causes of death during pregnancy or within 42 days of the termination of pregnancy in defining pregnancy related deaths [World Health Organization, 1977, International Classification of Diseases. Manual of the Internal Statistical Classification of Diseases, Injuries and Causes of Death, Ninth Revision, Geneva.].
But Tenth revision of the ICD includes two new categories defined as causes of maternal mortality. The first category is of “Late Maternal Deaths” that occur between 42 days and one year while the second category, on the other hand, includes a “Time of Death” definition among the pregnancy related deaths. This category includes any death in pregnancy or within the 42 days of termination of pregnancy irrespective causes [WHO, ICD- 1983: 1986].

On the other hand, in any kind of Indian context this matter requires a significant consciousness, especially in terms of socio-psychological support to the women from its early adolescent age, which prepares them to face pregnancy related complications psychologically. Women are between two and three times more likely to experience depression and anxiety than men. Pregnant women or those caring for infants and young children are more vulnerable. Depression in women during pregnancy and during first year following birth has been reported in all the cultures, though the rates vary considerably, but the average in industrialized countries is about 10-15%. Contrary to earlier perception, higher rates are reported from developing countries. Many factors contribute to maternal depression during pregnancy and post-natal period, including lack of practical and emotional support, or criticism from relations, particularly in-laws. Apart from other risk factors, the infants and children of mothers suffering from depression, especially those experiencing social disadvantage, have significantly lower birth weight, are more than twice as likely to be underweight at the age of six months, are three times more likely to be short for age at six months, have significantly poorer long-term cognitive development, have higher rates of anti-social behavior, hyperactivity and attention difficulties and, more frequently emotional problems [The World Health Report 2005: Make every mother and child count, Pg- 65. Published by the World Health Organization, Geneva.]. It simply means that maternal health concerns require urgent social action on priority.

Response of the State to Maternal Mortality

Government of Madhya Pradesh in its policy document admits that in spite of the best of efforts on behalf of the Government institutions, the people of the state are not satisfied and the health status, though improved from yesteryears, is far worse compared to the national scale (as reflected by the health indices). For every 100 rupees spent on health, Rs 75 come from private (out of pocket) sources. In the last Budget of the GoMP the overall per capita on health care is Rs. 150. Although Government Health Expenditure has risen in absolute terms, it has by and large remained static in per capita terms. As far as structural reform to provide better maternal health care is concerned, a lot remains has to be done.

In the rising tide of privatization of the Health services, the Government of MP also believes that only private participation could save women from maternal deaths. The Government is of the view that though the share of salaries in non-plan health expenditure is 86.7%, however, the government is not getting fair returns on its investment in health care and there is widespread dissatisfaction with the access and quality of health care in the government health care institutions. On the other hand, there are serious questions about the economic access and quality of health care in private sector, particularly in the rural areas. The problem is compounded as government does not have an effective monitoring, surveillance or control function with regard to private health care.

Three delays and one life

Every pregnant woman is under risk of death and when we keep an eye on the causes of maternal deaths, we see that there are three delays become common cause of death. These delays are- 
Delay-1: Delay in decision making to seek care. It is an important factor because decisions of getting maternal health care are always taken by the family members, who do not aware about the fact that excessive labor pain (more than 12 hours) is a big cause of women’s death. There different factors responsible for this delay are- Poverty, Distance, Availability of roads and transport facilities.
Delay-2: Delay in reaching to the health care facilities due to distance and unavailability of roads and transport facilities.
Delay-3: Delay in receiving adequate qualitative treatment. Usually it is found that the issues of sensitive human behavior, sanitation, availability of medicines-doctors are not taken seriously.

It is matter of concern that State government could not finalize State Health Policy in last 4 years and the policy is still a Draft Policy. There is thus no point in asking the question as to when the implementation of the following goals would begin-

1- Ensuring geographic and economic access to primary and secondary quality health care family services to the entire population of Madhya Pradesh within a span of five to seven years. Following will be the core characteristics of the health care:

• Health care would be gender sensitive
• Health care to address health promotion, prevention, treatment (curative) and rehabilitation.
• All health care resources including NGOs and private providers would be utilized for health care provision.
• Public fund would be primarily focus on rural and urban poor.
• Focus will be on communicable diseases (diseases of poverty), reproductive health conditions and preventive actions to reduce chronic diseases e.g. Cardiovascular diseases, cancer, mental disorder, diabetes (secondary prevention), hypertension (secondary prevention) etc.
• Address the increasing incidence of injuries by prevention and treatment.

2- Prevention of disaster, to the extent possible, and preparedness for disaster management as and when necessary.

3- Reducing the MMR to 220 by 2011 from the level of 498 (1997 level).

4- Reducing the IMR to 62 by 2011 from the level of 97 (1997 level).

5- Total Fertility rate to reach replacement level fertility (i. e. TFR of 2.1) by the year 2011.

6- Stabilize the prevalence of HIV/AIDS at low level (present level) and further decrease it.

7- Address problems related to mental health and initiate action to create information base and preventive intervention for improved mental health in the state.

How does one look at the financial aspect of this issue? As state accepts the fact that from health financing perspective, for every Rs 100 spent on health care in MP, Rs 75 come from out of pocket – private funding. For the service provision, there is a clear rural urban divide – 70% of qualified providers (doctors) are in urban areas and only 30% in the rural areas of the State. Seven out of about eight persons in selected health care staff categories work in the private sector. This does not include the public sector health employees (e.g. doctors, nurses and others) who practice privately after the duty hours [Draft State Health Policy, www.mp.nic.in/health].

Despite so many deaths of infants, neither the local administration nor the State administration has taken any note. Everyone who should have been concerned were busy welcoming the change in power and leadership and dying mothers could not find space in the priority list of policy makers and political parties.

Reality of Scheme based approach

Deendayal Antyodaya Upchar Yojana

Last year, the Madhya Pradesh Government initiated the Deendayal Antyodaya Upchar Yojana aimed at providing at least 22.05 lakh people with better health facilities. Under this scheme, a card decorated with pictures of political leaders was released at a grand function. This scheme has the provision of free health services up to Rs 20,000 per annum for poor families [Data obtained from the Right to Information section of Health department from www.mp.nic.in.].

For this purpose Rs 1.50 crore has been allotted in the annual budget. If Government’s achievements are to be analyzed in this context, only Rs 1.06 crore has been spent on the scheme and hardly 14,365 poor people have been treated [Data obtained from the Right to Information section of Health department from www.mp.nic.in.]. The basis for the allotment of such a meager budget towards conservation of fundamental rights (read health facilities) for the deprived classes of society is quite questionable. It goes without saying that an allotment of Rs 1.50 crores as annual budget for 22 lakhs targeted beneficiaries is nothing but a big joke. More over the benefits of this scheme are obtained only through political influence.

Transport and Treatment Scheme for Safe deliveries

The Government is also campaigning intensively for its transport and treatment scheme for delivery in the name of getting women their maternal health rights. This scheme has provision of Rs 150 to 300 to transport a pregnant woman to and from the health centre but the total budget is just Rs 1.03 crores for 5, 97,700 entitled women [Data obtained from the Right to Information section of Health department from www.mp.nic.in.]. Out of this amount, hardly Rs 32.12 lakhs [Data obtained from the Right to Information section of Health department from www.mp.nic.in.] was spent in Madhya Pradesh while the State faces the most serious threat of increasing death rate during and after pregnancy. A study conducted by the Center for Advocacy reveals that 53. 7 per cent actual beneficiaries are not aware of any such scheme and among those who know, hardly 0.8 per cent have been benefited from it. They believe that they cannot obtain any benefits from the scheme as no help is extended to them as per procedure.

National Maternity Benefit Scheme

The Commissioners of the Supreme Court in their Sixth report questioned the character of the State regarding implementation of the directive of apex court on the National Maternity Benefit Scheme. The Supreme Court in its order dated November 28, 2001 directed State Governments/Union Territories to implement National Maternity Benefit Scheme (NMBS) by paying all BPL pregnant women Rs 500, 8-12 weeks prior to delivery for each of the first two births. In other words, the most important feature of this Supreme Court of India order was to convert the scheme into a universal entitlement of all BPL pregnant women. The Court order was an important step towards maternal relief as a source for ensuring food security needs of women and her children, during the critical maternity stage, who were hitherto not covered by any form of social security targeted for this stage. This also for the first time ensured maternity relief as a legal entitlement for women in the unorganized sector, who are glaringly, denied the need for special care during this period [Sixth Report of the Commissioners to the Supreme Court, December, 2005, Page No.187].

But the reality is far from satisfactory. The analysis establishes that the Government of Madhya Pradesh has been highly un-accountable in implementing this scheme. In Madhya Pradesh, the Government provided benefits of this scheme to 22,346 BPL beneficiaries against the annual target of 5,97,700 to cover BPL pregnant women – which means that the State could provide right to care only to a fragment of 3.7 per cent of the total entitled women [Data obtained from the Sixth report of the Commissioners to the Supreme Court, December, 2005, Page No.189.].

Despite a peaceful society, political stability and abundance of natural resources, Madhya Pradesh continues to race ahead in death rate of mothers-to-be and young mothers. At least 498 out of one lakh women die during childbirth. Seventy-seven per cent childbirths take place outside hospitals and untrained persons in Madhya Pradesh manage 53 per cent births.

As a result, 70.87 per cent women died due to excessive bleeding, infections, insecurity and high blood pressure. A study done by the Bhopal based group, Centre for Advocacy reveals that only 35 percent people know about such schemes and six per cent have availed of its benefits. The life of a common woman is dependent on typical food habits and age-old traditions, which are far from humane. Most of the time she is given leftovers to eat, her nutrition is uncared for, the very social and family atmosphere in which she lives and breathes draws outlines of her bleak unhealthy future. A sick life is hounded with dearth of proper nutrition, security, entertainment and independence. She has no right to nutrition.

Pregnancy is in itself the most creative characteristic of nature, but in reality it is the most painful for a common woman. Be it physical pain, mental pain or social taboos, everything is somehow related to pregnancy. The truth is that while only 43 per cent women get their deliveries done under trained `dai’s (midwives), 77 per cent women do not feel the need of medical facilities and undergo unsafe deliveries. Not less than 59 out of every 10,000 women die during childbirth. This argument that that woman stays hungry because of poverty is wrong. Had this been true, 80 per cent women would not have fallen prey to anemia. The bitter truth is that be it high, middle or lower class, women are not provided with adequate nutritious food, mainly because of inherent traditions. The Madhya Pradesh Human Development Report and National Family Health Survey-II reveals that only 20.3 per cent women consume milk or curd daily whereas hardly 43 per cent consume Dal. It also reveals hardly five per cent get to have fruits and only 0.9 per cent women consume eggs and just about half a per cent women consume other non-vegetarian food. In fact the male dominated patriarchal social system today is weakening the women folk physically and mentally with the result that she is not able to contest for political power and challenge male chauvinism.

Similar to women, children stand in the queue craning for a better life. January to December 2004 estimates provided by the Directorate of Health Services say that only 605 children died of gastroenteritis, diarrhea, cholera, jaundice and meningitis. If this claim is true how 98,000 deaths of children as per the prevailing death rate of children occurred, is a million dollar question. When it is said that children are dying of malnutrition, Government tries to cover it up claiming that deaths occurred due to diarrhoel diseases, measles or gastroenteritis. Now the estimate of deaths due to these diseases is also being hushed up brutally. Naturally, if the seriousness of the disease is not accepted, efforts for its honest treatment are a far cry.

It leads us to think that the State now wants society to shed all its hopes of provision of health services so as to throw open the medical field to the market and multinational companies. Probably this is the reason why the budget allotments in this area have been receding at a fast speed. Under the present conditions, Madhya Pradesh Government spends only Rs 150 per person [Source- http://www.mp.nic.in/health/healthpolicy.HTM] every year on health facilities but forgets to publicize that out of this amount too, Rs 126 is spent on salary, transport and administrative expenses, so the actual per capita amount spent by the Government is just Rs 24 which means Rs 2.00 per month and seven paise per day.

Under these circumstances, does not the commitment of government become questionable? Is the need not felt that health should be given the status of fundamental right and every act of negligence in this regard be considered punishable by law?

Strategic lack of Information - No analysis, No accountability

It is most unfortunate that the State is still unable to conduct a mapping exercise to prioritize the most vulnerable Socio-Economic-Political zones of the State experts say that district wise survey of the Maternal Mortality is not a possible effort to make. It is ironical that though we have all the local level data of poverty, population, education-literacy, employment and even the most complex Bio-Diversity analysis (because market is taking interest in the rich natural resources of the state), nothing seemingly is being done for maternal mortality analysis.

In this context, A. Ranjan of Population Resource Center of RCVP Narohana Academy of Administration (Bhopal) has done an estimation exercise to chart out the burden of Maternal Mortality at the decentralized level. The final estimates again prove the apprehension thought that the women of Schedule Case and Schedule Tribe dominated areas are suffering the most. Among the districts of the undivided Madhya Pradesh, the risk of maternal death has been found to be highest in district Sidhi (1044, Tribal dominated), followed by district Chattarpur (932, Dalit dominated), district Jhabua (895, Tribal dominated), and district Satna (804, Dalit – Tribal).

In these districts, the life time risk of a maternal death is estimated to be less than 25 – one in less than 25 women in these districts face the risk of death due to complications of pregnancy and delivery during their entire life span. On the other hand, the lifetime risk of maternal death has been found be the lowest in district Indore (which is a urbanized and industrial district), where the MMR is estimated to be 208 maternal deaths per 100,000 live births [Obstetric Care in Central India, Ed.- Alok Ranjan & R William Stones, Pg-45, published by University of Southampton, 2004]. There is also a strong need to see the relation between other human development indicators and the Maternal Mortality Ratio. It has close links with the socio-economic level and Child malnutrition similar to caste factor. It can be summarized that high vulnerability in all these aspects lead to high MMR.

At this point of time we can analyze our achievements in terms of goals of reduction in MMR to 220 by the year 2011. In the present status 4 out of 48 districts may achieve the target but in rest of the districts, there is little hope of any substantial gain in reducing maternal mortality unless the issues of social inequality, gender disparity and access to the Health services are addressed. It is also to be seen whether enough financial provisions have also been made to achieve the goals of Madhya Pradesh Population Policy. Government of Madhya Pradesh spends only a pathetic 0.92 percent of its total health budget to prevent maternal deaths.

Non availability of accurate information on different aspects of women health is a major hindrance in causal analysis. However, a look at various indicators of human development can help to establish a direct linkage between the problem and availability of basic infrastructure. Table -2 (as shown above) indicates that in the districts where maternal health care rights are violated, basic infrastructure is lacking. A look at the data tell us that only 7.3 percent pregnant women in Sidhi, 11.7 percent in Shahdol, 10.7 percent in Mandla had deliveries in institutions. This means that number of women dying due to pregnancy related compaction is quite high in these districts. Interestingly 55 – 70 % of villages in these districts have no road connectivity.  Why only roads? If one dwells deep into various indicators of socio development these districts rank poorly on the same. This has a major impact on maternal mortality and the percentage of safe deliveries is extremely low in these districts. Only 10.4 percent pregnant women have chance to safe delivery while in Sidhi it is 7.3 percent, in Mandla 17.6 percent and 16.9 percent in Satna. It is an established fact that without ensuring complete ante-natal care facilities, that too within the reach of people, one cannot dream of providing safe motherhood in the state. There is need of strong political will to step up investment on priority in the areas of basic health infrastructure. Government of Madhya Pradesh has raised its investment on construction of roads but in terms of other basic infrastructure it has long way to go.

State Government today feels the need to change the current model of primary health centers for 30,000 population to make them functional and cost-effective, especially in areas of outpatients’ services and emergency care.

Number of PHC in terms of population and its impact on efficacy and maternal mortality is one more issue which needs to be looked into. At present the norm is that there would be one primary health centre on a population of 30,000. But is this number sufficient and whether it is possible to cater to such large population in sparsely populated tribal dominated districts is point to note. Shahdol and Mandla districts have only there is one PHC at the population of 24992 and 28639 respectively and only 11.7 and 10.7 women had availed the facility for institutional deliveries. Unfortunately the norm of one PHC per 30000 populations is not based on the ground realities and does not take care of the variable population density in the state and country.

The experiences gained till date can surely give some points to internalize the pain more than a figure. Now the government has also started realizing the need of Cost-effective interventions to reduce MMR range from the presence of skilled attendants at the time of birth, involving a combination of personnel, drugs and back up emergency care, better nutrition, good antenatal care and tetanus toxoid injections during pregnancy. Several non-health interventions can also help to reduce the MMR: age at marriage and enhancement of women’s status in society, which may be associated with improved nutrition and education. Unfortunately, changes in these ‘cultural characteristics’ occur slowly over time, and cost effective interventions to influence these characteristics are not readily identifiable [Report of the National Commission on Macroeconomics and Health, Govt. of India, September, 2005 pg- 37]. It is also to be analyzed that whether the structure and character of our state permit us for innovations to change in Cultural characteristics maintaining ownership, commitment and transparency. We can see that women are going to be the biggest sufferer in the debate of increase in population on the religious basis and state is still behaving as a silent viewer. Although this confession make sense that the NHP, 1983 made a strong policy commitment to establish comprehensive health care, based on the active involvement of the community and inter sectoral linkages to health determinants such as nutrition, water, sanitation, etc. Such an approach, if implemented, would have helped aver the premature death of an additional 1.50 million infants and 800,000 maternal deaths [Report of the National Commission on Macroeconomics and Health, Govt. of India, September, 2005 pg- 48]. In continuation to this point now we also will have to look and counter the political calls to increase population by the fundamentalist forces.

Points of Action

The need of the hour is that we should accept this problem as a challenge to the society, which strongly believes in the human rights and struggling hard to achieve the status of equality and happiness. It is a challenge because we cannot justify our existence until we are able to protect women from the fire of Maternal Mortality. It should be accepted as a social disease and disaster rather than a technical problem.

There are several actions to be taken before we all go to sleep-

1. Firstly, there is a need to recognize the reality that women are getting thrown out of the concept, plan and action of equality based social development by being denied right to maternal health care. A lot of issues have been included in the priority list of the state and social movements but maternal mortality remains totally untouched.

2. There is a possibility of conducting Maternal Health Care audit at block level to check the situation, impact of efforts and identify new actions needed to ensure women's right to maternal health care.

3. Our analysis proves that situation is not serious just because 34 women die every day due to pregnancy and after pregnancy related complications, but because this issue is still out of the focus of social development indicators, plans and socio-political movements. Even State is not providing enough resources and infrastructure support.

4. More effective efforts are needed to ensure that the programs, activities implemented to reduce maternal health complications and obstetric care reaches every one in the community without any bias and discrimination, keeping in view the fact that the State of Madhya Pradesh is grossly dominated by the social discriminatory practices and gender bias.

5. It is also a fact that only 30 percent women get Pre-natal care, 74 percent are anemic, they are socially food insecure, having no decision making rights even to fulfill their own health needs. Keeping these facts in mind, this should be noted that pre-natal care is linked to improved maternal health but in isolation is not enough to ensure a reduction in maternal risk. It simply means that prenatal care must be backed up by regularly available high quality health services.

6. Whenever we talk about health services in terms of maternal mortality, it should be seen as a comprehensive package of socio-economic and psychological supportive system.

7. As far as Madhya Pradesh is concerned, to fulfill women's right to access basic maternal health services, the present health care system strongly needs to be restructured and strengthened to make it more functional, efficient and accountable.

8. In this context, Report of the National Commission on Macro Economics and Health (Government of India, September, 2005) is to be taken note of, which says that the existing system has collapsed in several parts of the country for reasons other than funding. Lack of accountability, rampant indiscipline, corruption and weak governance and poor management characterize the functioning of the public health infrastructure in the country, more noticeably at the primary level. This needs correction, but such correction will be possible only by making the system incentive-oriented and the active participation of the civil society. Bu similarly active participation of the civil society will not work, we will have to look for the pro-active participation in the entire process of change.

9. The matter of Maternal Health care should not face financial constrains at any level. It is very unfortunate that there is no specific budgetary provision to improve the situation of maternal mortality. It is only when pressure from civil society or international donor agencies is created than our governments start acting on this issue; otherwise it is not at all their priority.

10. There is a need to counter commercialization of basic health services by making it more community based and transparent. Community- based obstetric care services can help educate people about safe delivery practices, viz how to recognize complication and where to go if they arise, but these services cannot cope up with serious health complications. Success of the community-based services depends upon the availability of and access to services that can treat the complications arising out of pregnancy and delivery. Based on the experiences gained from different parts of the world, at least two issues can be identified that are critical to improving maternal health status of the people - proper medical attention and care during pregnancy and childbirth and social and economic conditions and life style patterns. Among the two, the importance of proper medical care and attention lies in the fact that most of the effects of social and economic conditions and life style patterns operate via attention and care during pregnancy and at the time of the childbirth (Ref.-Obstetric Care in Central India, Published by University of Southampton).

11. It should always be kept in mind that we are discussing these points about women's maternal health rights in a patriarchal society and our policy makers, politicians, health sector professional all belong to the same society where these rights are violated on a regular basis.

12. We should also suggest that the health personnel should be trained in socio-psychological healing techniques. They should understand that women, who need maternal health care face high emotional pressure, which if is not controlled it becomes a biggest cause of maternal deaths.

13. It is commonly found that provisions in the different schemes are made on the basis of numerical ceiling basis, limiting the access of the beneficiaries to these schemes. Another relative point is that Panchayat and village level health committees should be empowered to identify the beneficiaries and monitor the use of funds. Local bodies should be answerable to the Gram Sabhas and social audit of these schemes should be made compulsory on a regular basis.

14. There is a need to substitute the scheme-based approach with the universalization of maternal health facilities. To make this happen rights based approach has to be adopted and efforts have to be planned in people’s campaign / movement mode.

References

¹ The estimates of maternal mortality ration are based on the estimates of infant mortality rate obtained through the Madhya Pradesh Target Couple Survey 1996 {Chaurasia, 1999} and estimates of the proportion of safe deliveries obtained through the rapid household survey under the Reproductive and Child Health Programme, IIPS 
² Identification of Poor through BPL Census in Madhya Pradesh – 2002, A participatory review of Method and Process, Conducted by the Alliance for Democratic Initiative for Self-Governance (ActionAid International, Bhopal) 
³ Final data of Bal Sanjeevani Malnutrition Eradication Campaign, Dept. of Women and Child Development, GoMP, May-2004
⁴ Third Human Development Report, Madhya Pradesh, 2002-Pg-465
⁵ Third Human Development Report, Madhya Pradesh, 2002-Pg-474
⁶ Third Human Development Report, Madhya Pradesh, 2002-Pg-446
⁷ Third Human Development Report, Madhya Pradesh, 2002- Pg-473

Sachin Kumar Jain