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INDIA: Return of Traditional Birth Attendants Urged to Meet MDG 5

Ranjit Devraj

NEW DELHI, Oct 14 2009 (IPS) - As India struggles to lower one of the world's highest maternal mortality rates, activists and experts are calling for a revision of polices aimed at "institutionalising" deliveries in resource-poor rural settings and phasing out the 'dai' or traditional birth attendant (TBA).

According to a report released last week by Human Rights Watch (HRW), India's maternal mortality rate is 16 times higher than Russia's and 10 times higher than China's. Also, in several parts of the vast country, the rates have been worsening in spite of various government schemes and programmes – and possibly because of them.

In 2005, the maternal mortality ratio (MMR) in India was 450 per 100,000 live births, slightly lower than the average ratio of South Asia (which comprises the country), estimated at 490, considered the second highest by region, next to African.

According to the United Nations Children's Fund (UNICEF) an estimated 80,000 Indian women, either pregnant or new mothers, die each year from preventable causes, including haemorrhage, eclampsia, sepsis and anaemia.

The HRW report, 'No Tally of the Anguish: Accountability in Maternal Health Care in India,' focuses on India's most populous state of Uttar Pradesh to show persistent failures in providing care for pregnant women. It also identifies caste discrimination, lack of accountability and limited access to emergency care as chief causes of maternal deaths.

Annie Raja, general secretary of the Communist Part of India-affiliated National Federation of Indian Women (NFIW), told IPS that the failures were at least partly driven by policies blindly designed to meet the fifth Millennium Development Goal (MDG5) of reducing MMR by three quarters by 2015.

MDGs are eight development goals to be achieved by 2015.

''There is a belief that MMR can be brought down by increasing skilled attendance at deliveries without considering realities on the ground such as non-functional or absent primary health centres as well as lack of personnel and funds," said Raja. A key MDG5 prescription is to maximise the number of births attended by skilled health personnel.

In India this has meant a gradual phasing out of the 'dai' or TBA, who is considered illiterate, unskilled and difficult to train in the handling of pharmaceutical drugs that may be required during a birth emergency.

Until 2005 when India launched its flagship National Rural Health Mission, some of the country's estimated one million 'dais' were also given training and had some recognition, but they have since then been steadily replaced by Accredited Social Health Activists (ASHAs) whose main job is to register pregnant women and encourage them to seek institutionalised care at government facilities.

An ASHA (which translates as 'hope' in Hindi) must be literate and have received primary education until class eight. She acts as a primary health worker and receives incentives for providing referral and escort services for pregnant women to health care centres.

But there are real practical problems, said Raja. "An ASHA gets just 600 rupees (12.8 US dollars) per live delivery in a government facility and is expected to bear the costs of transporting the pregnant woman and other costs along the way. If the delivery takes place outside the hospital premises, she gets nothing and then she has no training in midwifery."

"Also, while the programme promised 'concrete service guarantees' such as free care before and during childbirth, emergency obstetric services and referral in case of complications, beneficiaries were limited to women classified as living below the poverty line or else belonged to tribal or 'dalit' (low caste) groups," Raja said.

While a few 'dais' turned into ASHAs, the literacy criterion ensured that the vast majority of them got excluded, along with skills gained through sheer experience.

"There is nothing wrong with the concept of 'skilled attendance at birth' as defined by the World Health Organization [WHO] and UNICEF except for the simple fact that basic health services are simply not available to the vast majority of people in India," said Raja.

Dr Usha Shrivastava, a former researcher at the prestigious All-India Institute of Medical Sciences, said the problem is one of resources. "’Dais’ provided a real service by operating in areas far away from any centre where a skilled birth attendant (SBA) may be available and deal with pregnant women who are often anaemic, malnourished and have no access to safe drinking water and, therefore, already compromised," she said.

Shrivastava, editor of 'Health Positive,' a journal that specialises in 'best practices in clinical and public health,' said that even if qualified doctors or SBAs can be taken to remote rural areas, there is little that they can do in a birth emergency in a setting where there is no electricity, blood bank or sterile settings.

Usha and Raja are not alone in their view that 'dais' should be empowered rather than phased out, as envisaged under MDG5.

A team of researchers led by Anthony Costello at the department of child health at University College, London, reported in 2006 that while TBAs were not a substitute for trained midwives, they were the main provider of care during delivery of millions of women, especially in settings where mortality rates were high.

"Since 1990 international agencies and academics without robust evidence have persuaded governments to stop training programmes for traditional birth attendants," Costello commented in the British 'Lancet' journal.

Many national policies promoting institutionalisation of birth deliveries follow the ideals of the 'Safe Motherhood Initiative' launched in Nairobi in 1987 by the WHO, UNICEF, the United Nations Population Fund and the World Bank and by the International Conference on Population and Development in 1994. In September 2000, 189 world leaders committed their nations to the MDGs, which included improving maternal health.

Raja said that in India a medical elite and a bureaucracy anxious to tote up figures showing increasing institutionalisation of deliveries have forgotten the harsh realities of rural India. "It is not difficult to see why, in spite of various government policies, only 17 percent of all deliveries in this country take place in a hospital or are attended to by an SBA," she said.

Raja said the best way out is to develop alternate strategies that recognise the services and skills of TBAs, and incorporate them into the health system in such a way that women in the rural areas and those that belong to marginalised groups are adequately covered.

Gargi Chakravarthy, a Delhi University historian and an activist with the NFIW, said the marginalisation of TBAs or 'dais' stretches back to British colonial times and has continued into contemporary India through policies drawn up by a bureaucracy with colonial moorings. "We need firstly to reorient the bureaucracy to current realities," she said.

Chakravarthy pointed to copious documentation that shows the systematic devaluation of traditional health practitioners under colonial rule and the gradual replacement of the 'dai' by "lady health visitors" who promoted modern obstetric practices. The colonial period also saw the setting up of many hospitals where lying-in care was first made available for pregnant women.

"It was possible for Britain and other industrialised countries in the West to drastically reduce maternal mortality in the last century by providing professional midwifery care and by improving access to hospitals. This model was later followed by developing countries, but success depended crucially on the existence of a functioning health delivery system," Chakravarthy said.

Raja believes that the success of MDG5 lies in first implementing MDG3, which calls for the promotion of gender equality and the empowerment of women. "Too many of the decisions in public health are made by men while women's voices and concerns are routinely ignored."

"Last week's HRW report," said Raja, "comes as no great surprise when the cruel reality is that the public health system, which was once a mainstay of healthcare for more than 75 percent of the population, has fallen into neglect through the privatisation of health care and reduced budgetary allocations that now stands at slightly more than one percent of GDP."

"There is also the question of political will. Surely a country that calls itself an emerging power produces world-class doctors, has some of the finest medical facilities anywhere and promotes medical tourism can find a way to reach meet the MDGs," Raja said.