One of India’s greatest public health successes has been the dramatic fall in maternal and infant mortality throughout the 21st century. The Maternal Mortality Ratio (MMR) in India — maternal deaths per 100,000 live births — that was 384 in 2000 had fallen to 103 by 2020. There is much more access to modern health care. In 2019-2021, 89% of babies were born in hospitals and other health care institutions, compared to just 41% in 2005-2006. The quality of care has improved within institutions as well, saving even more lives.
But is it enough that more women and infants survive?
As United-States-based maternal health expert Neel Shah says, survival is just the floor of what people deserve during childbirth. We should be aiming for the ceiling — not only survival, but also good health and quality of life; dignified, respectful, and positive birthing experiences; and memories of fulfillment and joy at the arrival of a new family member.
To get to that aspirational ceiling, we have to understand the three key challenges in India’s maternal health landscape.
First, we must address the problem of ‘too little, too late,’ that is, inadequate care, or delayed care. For example, not having access to skilled health care providers, medical facilities, ambulances, or drugs. Despite overall national progress, vast swathes of the country still suffer from too little, too late. We are still losing too many mothers and babies.
Second is the issue of ‘too much, too soon’, which refers to the problem of routine over-medicalisation; unnecessary use of harmful and non-evidence-based interventions; and the use of interventions that can be life-saving when used appropriately, but detrimental when overused. Pregnancy and childbirth are physiologic processes, not an illness. Too much, too soon leads to unnecessary morbidity for the mother and newborn. In India, this can be seen in extremely high rates of Caesarean-sections (C-sections), labour inductions, augmentations, and episiotomies. Public health research suggests ideal C-section rates are in the range of 10-19%. India’s nationwide private sector C-section rate is 47%, and many states and districts cross 80%.
Third, Disrespect & Abuse (D&A) of pregnant women and women in labour is rampant across India, with an estimated prevalence of around 71%. D&A is an inherent violation of human rights. It takes several forms, such as physical and verbal abuse, a lack of informed consent, a lack of privacy, and a lack of confidentiality. It is present in varying degrees based on the facility type, and is compounded by factors like caste and socio-economic status. Widespread D&A leaves women feeling disempowered. It also reduces willingness to seek institutional health care, which, in turn, drives up mortality.
Neither poor quality of care, nor D&A, are limited to low-income settings. Usage of harmful, outdated practices happens across India, and even privileged women thus bear a lot of unnecessary morbidity. Moreover, women in elite urban hospitals also experience D&A, particularly through a lack of informed consent and a lack of bodily autonomy. While they may be consenting to procedures and interventions in a legal sense, this is often after being misled through fear-based consent processes in which the true benefits and risks are not conveyed.
The barriers women face in maternity care are complex. It is an issue that suffers from sitting at the intersection of India’s challenges in both women’s disempowerment and health care. Women suffer from public health shortcomings, just as men do, but face additional mistreatment. Moreover, women often have low bargaining power within their own households, which makes it difficult for them to demand high-quality or respectful care.
We need to situate the maternal health conversation within the larger feminist debates on bodily autonomy and women’s rights. With growing recognition of mistreatment, abuse, and neglect of women giving birth in facilities, what we need is a paradigm shift.
We must stride towards a world in which women not only survive, but also receive high-quality care that is compassionate, respectful, and empowering.
Childbirth need not just be something to tolerate in order to have a baby. Positive birthing experiences, protection of human rights in childbirth, and optimum health for mothers and babies should become the norm. It is time to transform birthing.
Janhavi Nilekani is founder and chairperson, Aastrika Foundation and Aastrika Midwifery Centre. The views expressed are personal
