In a country where 73.5% of women in the reproductive age are anemic and 18.6% of children are born with low birth weight, the need for cash support in maternity cannot be disputed
It was the third pregnancy at the age of 27 that killed her. Her daughter was born soon after marriage and a son, two years later. During her third pregnancy, the 27-year-old illiterate tribal who lived in Odisha’s Mayurbhanj district had three antenatal check ups and, when found to be severely anemic, was given iron tablets. The ASHA (accredited social health activist) urged her to see a doctor. But, she said, she could neither afford the fee nor the cost of travel. Her husband was an alcoholic and it was her daily wage earnings that supported the family.
When she went into labour on 24 April 2014, the family paid the auto rickshaw driver ₹ 300 to take her to the district headquarters hospital 45 minutes away. The gynecologist found her pale and severely anemic and started IV fluids. She gave birth a little after midnight but three hours later when the bleeding wouldn’t stop, the nurse informed the ASHA and family to arrange for blood. By the time the hospital could start transfusing, it was six hours after delivery. She died soon after dawn.
The woman is referred to simply as ‘04’ in the report, Chronicles of Deaths Foretold released in August 2016 by the National Alliance for Maternal Health and Human Rights (NAMHHR) and the NGO, Sahayog. The report documents 140 women who died in childbirth in seven districts from the states of Odisha, West Bengal, Jharkhand and Uttar Pradesh. Like ‘04’, most of the 140 women came from marginalized communities including scheduled castes, scheduled tribes and Muslims. Almost all were poor, had negligible levels of education and virtually no access to health information. Almost all were characterized as ‘high-risk’ due to frequent childbirth, anemia and low weight.
In nearly every case, it’s the same story: more and more women are choosing to have their babies in hospitals. But, while hospitals seem to cope well with routine deliveries, it’s a vastly different story when it comes to emergencies. Poor, marginalized families already under stress are more often than not expected to run around, arranging for blood. By the time it arrives, it’s too late.
As many as 10 women would have died in childbirth in different parts of India in the roughly two hours it took for finance minister Arun Jaitley to present the budget in Parliament. In a country that accounts for 17% of all global maternal mortality deaths, nobody can dispute the need for the Pradhan Mantri Surakshit Matritva Abhiyan intended to provide comprehensive antenatal care to pregnant women.
Out of an allocation of Rs22,095 crore for the ministry of women and child development–an increase of 27% over the previous year–Jaitley also announced Rs2,700 crore for the maternity benefit programme.
In addition, Mahila Shakti Kendras at the village level, intended to empower women with skill development, digital literacy and health and nutrition, get Rs500 crore. Allocations for the Prime Minister’s flagship programme Beti Bachao Beti Padhao have been doubled to Rs200 crore.
Prime Minister Narendra Modi’s New Year’s Eve announcement of Rs6,000 cash entitlement to pregnant women is an extension of an existing scheme, the Indira Gandhi Matritva Sahyog Yojana (IGMSY) operational in 53 districts. Moreover, the National Food Security Act (NFSA), 2013 also has a special focus on women and children with the provision of Rs6,000 to pregnant women. But this has never been implemented in any state except Tamil Nadu, Gujarat and Odisha.
Regardless, a maternity entitlement scheme can only be welcomed in a country where maternal mortality at 174 per 100,000 live births in 2015 falls far short of the Sustainable Development Goals of 70 by the year 2030.
How is the money to be disbursed? Half at the end of the first trimester, following registration of the pregnancy and one checkup; Rs1,500 at the time of institutional delivery and the balance Rs1,500 after the birth is registered and child has received its first inoculations, clarifies a press release by the women and child development (WCD) ministry.
But activists are concerned about the government’s calculations of 51.7 lakh potential beneficiaries of the scheme. With an estimated 27 million live births a year, the government’s figures could be a ‘gross underestimation’, says Yamini Aiyar, senior fellow, Centre for Policy Research, conceding that all 27 million who give birth will not be eligible for the payout.
Adds Kanika Kaul, senior programme officer with the Centre for Budget and Governance Accountability (CBGA), “The government’s own report by the standing committee on Food, Consumer Affairs and Public distribution presented in January 2013 puts the number of eligible women at 2.25 crore every year." This works out to Rs14,512 crore a year.
Depending on who you talk to, the maternity entitlements scheme could cost the exchequer anything between Rs14,000 crore and Rs16,000 crore plus – far more than the press release estimates of Rs12,661 crore spread over three years.
“The priority is women as reproductive agents rather than as economic agents," says Ritu Dewan, president, Indian Association of Women’s Studies. “The allocation of Rs500 crore for Mahila Shakti Kendras is not enough. Even Dangal made more profit."
Others are concerned that the maternity entitlements fine print would impose conditions– say a cap on two live births. “This would mean that the poorest and the most vulnerable could be denied the benefits of the cash transfer," says Jashodhara Dasgupta, senior advisor, Sahayog that conducted the 2016 study on maternal mortality.
Poor nutrition compounded by inadequate care during pregnancy is the main cause of high maternal mortality. “The biggest burden of maternal and infant mortality falls on marginalized communities and the poor. The government does not publish disaggregated data on the socio-economic profile of maternal deaths," says Dasgupta.
In a country where 73.5% of women in the reproductive age are anemic and 18.6% of children are born with low birth weight, the need for cash support in maternity cannot be disputed. But it cannot be the only solution.
Maternal mortality is preventable with interventions that include good nutrition, antenatal care and skilled attendance at delivery. Says Dasgupta: “Cash cannot be a panacea but must be combined with improved health services and should move towards wage compensation for women employed in the informal sector or as daily wage earners."
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