Saving Women's Lives: Reducing Unnecessary Delays to Comprehensive EmOC
Vapari Bai’s death (Human Rights Watch, January 10, 2011) due to eclampsia in Barwani district hospital in Madhya Pradesh, India highlights the need of reducing unnecessary delays in reaching the appropriate health facility equipped to offer comprehensive emergency obstetric care (EmOC) services through an effective referral system, between communities and facilities without these services with those facilities equipped to offer these services. Investigation of maternal deaths, while important, may have an unwarranted side effect of providers refusing care to those who really need it.
It is well known that 15% to 20% of pregnant women experience life threatening complications (e.g. hemorrhage, sepsis, eclampsia, and obstructed labor) around the process of childbirth (pregnancy, delivery, and post-partum). However, these complications cannot be predicted well in advance, but they are the ones which require timely and appropriate care. What to do when these complications start to appear? Finding an appropriate solution has been a major challenge in efforts to reduce maternal mortality in developing countries.
The Government of India is implementing a very ambitious program of conditional cash transfer—the Janani Suraksha Yojna (JSY)—to reduce maternal mortality ratio (MMR) by promoting institutional deliveries. The district level surveys indicate an increase in institutional deliveries from 41% to 54% between 2002/04 DLHS-2 and 2007/09 DLHS-3. However, the statistical analysis of these data published in The Lancet failed to establish any effect of JSY on MMR.
A rise in institutional deliveries is likely to decrease MMR if women experiencing complications around childbirth are shifted from home to institutions with comprehensive EmOC, and if the case-fatality ratio (CFR) among women with complicated deliveries at these facilities decreases. However, CFR among women with complicated deliveries at health facilities, as highlighted by the death of Vapri Bai, may be increasing for two reasons. First, women experiencing complications during childbirth may also be experiencing additional delays in reaching the appropriate institution because they are first taken to health facilities which do not have comprehensive EmOC. Second, those reaching a facility with comprehensive EmOC services may not be getting appropriate care because of the increased workload due to JSY.
It is essential to increase the number of facilities offering comprehensive EMoC and to improve quality of care by training providers at these facilities to offer timely care to women with complications. In the meantime, it is essential to clearly identify and label facilities in a district/state equipped to offer comprehensive EmOC. In addition, providers at other facilities (CHCs, PHCs and even district hospitals) without comprehensive EmOC and providers in communities (ASHAs, TBAs, and Dais) must be trained to identify women experiencing complications and refer them directly to the facility equipped to provide comprehensive EmOC. Linking facilities without comprehensive EmOC to those with comprehensive EmOC through ambulances and other transport facilities would also help. Vapari Bai would, perhaps, still be alive if the family had the information to take her directly to the medical college hospital in Indore instead of first going to the district hospital and wasting valuable time and resources.