INDIA: India Takes Step Forward in Tackling Maternal Health

Delhi's high court has ordered the capital's government to build shelters for destitute pregnant women so they can receive care when giving birth. It is treating maternal mortality as a human rights violation.

In January, Shanti Devi, a woman living below the poverty line, died after giving birth to a premature baby. She had not eaten for three days before her delivery. A few months later, Fatima, 24, a destitute woman who suffered from epilepsy, was forced to give birth under a tree on a crowded street in New Delhi. Her mother took her to a local government maternity home but they were turned away. Laxmi, another destitute, homeless woman gave birth and died on the streets of India's capital city in July. She was helped by another homeless woman. For four days Laxmi lay on the streets with her new born baby, then died of septicemia.

The experiences of Laxmi, Shanti and Fatima are not uncommon in India, where one woman dies every five minutes from preventable, pregnancy-related causes. These three women and their plight have exposed the huge gaps in India's tottering public health system that offers little or no emergency obstetric care, and continued care in the post-partum period for underprivileged women. But stories such as these have initiated a new era in maternal health activism.

Following Laxmi and Shanti's death, the Delhi high court, in a landmark judgment, ordered the government to build "at least two shelter centres meant for destitute pregnant women and lactating women so that proper care can be taken to see that no destitute woman is compelled to give birth to a child on the footpath". Earlier, the Delhi high court ordered the Delhi government to pay 50,000 Indian rupees (£680) to Fatima and Rs240,000 (£3,250) of Shanti Devi's family as compensation for denying the women their reproductive rights. The judgments are a major achievement for maternal health activists.

Aparajita Gogoi, the national coordinator of the White Ribbon Alliance for Safe Motherhood, India, an advocacy alliance of 1,000 organisations in India, called the judgment a "great step forward". Gogoi told The Guardian: "There are not many instances in India where people who work around maternal health have sought the judicial path. Such an action obviously ensures accountability. Thousands of women die every year in India and no one is held accountable for it. These cases would help spread awareness and hopefully also act as a deterrent. Next time, healthcare centres will think twice before denying life-saving care by turning away a poor, pregnant woman."

In the judgment, the government was criticised for its slow movement on reducing maternal mortality and said destitute, pregnant women and lactating women can't be allowed to die on Delhi's streets.

Sukti Dhital, a reproductive rights lawyer at the Human Rights Law Network (HRLN), who filed the public interest litigation after Laxmi's death, told The Guardian: "This is the first decision that we know of in the world to hold maternal mortality as a human rights violation, and order compensation and other relief against the government for such violations."

India has many welfare schemes for underprivileged women, such as the National Maternity Benefit Scheme (NMBS), Integrated Child Development Scheme (ICDS) and Janani Soraksha Yojana (mother's safety programme), a scheme to reduce maternal and neonatal mortality by encouraging institutional delivery for poor, pregnant women. However, India's maternal mortality continues to be higher than neighbouring countries such as Bangladesh, Nepal and Sri Lanka, and accounts for 25 per cent of the global maternal deaths. Ghulam Nabi Azad, the federal health minister, recently admitted that maternal mortality continues to be an area of "concern".

The Delhi ruling cited not only the problems in implementation of maternity benefit and food security schemes, but also in the framing of such schemes, which could have far-reaching implications for the whole country. However, maternal mortality experts warn that this ruling is just the first step and that constant vigilance is needed to ensure proper implementation of the judgment. After all Shanti Devi's family is yet to receive the compensation amount and Fatima received her compensation after much delay and only after legal action by the HRLN.

Meanwhile, the Delhi government has identified two community centres that can be used as shelters with appropriate medical and nutritional services. Dhital, from the HRLN, said they have been given clearance by the high court to examine the shelters, to ensure that they will be adequate. "It is of paramount importance that these exclusive shelter homes provide the medical, nutritional, and social services necessary to ensure safe motherhood," she said.

Laxmi's and Shanti's deaths come as figures emerge of a notable drop in maternal mortality – 59% between 1990 and 2008. However, the World Health Organisation and other UN agencies say that even though India is "making progress", it is not "on track" to meeting its target under the UN millennium development goals – to reduce by 75%, between 1990 and 2015, the maternal mortality ratio.

"We can bring down maternal mortality to a certain level but the last mile will be the most difficult. Women who are dying are uneducated, poor. They are not in a position to take decisions about their own healthcare," said Gogoi. "The biggest challenge will be ensuring access to life-saving care to these women. We have a lot of work to do at the community level."

Millennium development goal 5: Improve maternal mortality

1. What is the goal? To reduce by three-quarters the maternal mortality rate and achieve universal access to reproductive healthcare. The goal looks at the proportion of births attended by a skilled health worker, contraceptive prevalence rates, adolescent birth-rate and ante-natal care coverage.

2. Progress so far Under-reporting makes this a difficult goal to accurately assess and progress varies widely across countries. With the exception of north Africa and parts of Asia, progress has been slow. However, in about one-third of developing countries, skilled health workers now attend 95% of all births, and nearly 20% have almost universal access. Birth attendance is still low in countries in sub-Saharan Africa and south Asia, though. The urban-rural gap in antenatal care has narrowed slightly. Access and use of contraception is still lowest among women from poor households.

3. Likely to be met? No. Progress is too slow to hit the target in time.