SHORT REPORT 294
Are we really making motherhood safe? A study of provision of
iron supplements and emergency obstetric care in rural
SARIKA CHATURVEDI, BHARAT RANADIVE
Background. The Government of India launched the
National Rural Health Mission (NRHM) in 2005 to improve
healthcare delivery and strengthen the public health system.
Prevention and management of anaemia during pregnancy and
access to quality emergency obstetric care services are
important factors in reducing maternal mortality, which is a
priority goal in the NRHM. We studied the ground realities
specific to the availability of maternity services in the
public health system of Maharashtra.
Methods. The study was done in the rural areas of
Ahmednagar district in Maharashtra in 2006. Data regarding the
number and place of deliveries, and details regarding iron
supplements received and used were collected from 14 primary
health centres selected by a stratified random method. Data
regarding the number of caesarean section operations conducted
in 3 selected rural hospitals and the availability of iron
supplements at the district headquarters were also obtained.
Three questionnaires were used in the format prescribed under
the Right to Information Act of the Government of India, 2005.
Results. No iron supplement was available during
the entire year in 21% of primary health centres. Iron
supplements were available for 1–4 months, 5–8 months and 9–11
months, in 4, 3 and 4 primary health centres, respectively.
The district headquarters did not receive supplies of iron
supplements during the year from higher authorities. No
caesarean sections were done in any of the selected rural
hospitals during 2006. The proportion of deliveries that took
place in primary health centres and subcentres, at home, and
at private healthcare facilities was 1:1.5:5.
Conclusion. Essential supplies such as iron
supplements are in short supply and emergency obstetric care
services are non-existent in the public health system in our
study area. The NRHM needs to address the ground realities to
make motherhood safe.
Natl Med J India 2007;20:294–6
The links between care during pregnancy and maternal mortality
are well recognized. Over the past decade, national plans and
programmes in India have stressed the need for universal
screening for high risk pregnancies and for operationalizing
essential and emergency obstetric care. Goals set in the Tenth
Five-Year Plan have advocated an ambitious agenda to make
motherhood safe. This includes skilled attendance at birth for
80% of all deliveries by 2007, institutional deliveries for
65% of all births, at least 3 antenatal care (ANC) check-ups
for 90% of pregnant women, and universal coverage of complete
immunization during pregnancy. The launch of the National
Rural Health Mission (NRHM) in 2005 and the accompanying
influx of funds raised hopes for better pregnancy-related
care, and a consequent reduction in maternal mortality.
Maternal and adolescent malnutrition and anaemia are
important precursors of complications during pregnancy and
childbirth, and are also contributors to perinatal and
neonatal morbidity and mortality. In India, findings suggest
that almost half of all women are anaemic (48%) and about 17%
suffer from moderate-to-severe anaemia.1
Among adolescents who have or are about to experience
pregnancy, 20% are moderately or severely anaemic.2
Among other complications, maternal anaemia results in reduced
placental weight, volume and surface area; abnormal uterine
labour and abnormal deliveries;4
low birth weight and associated foetal, perinatal and neonatal
mortality. In addition, 15%–20% of maternal deaths are
directly or indirectly due to anaemia.5
Supplementation with iron and folic acid during pregnancy
is an effective method of preventing pregnancy-related
mortality and is currently recommended in various government
policies. We assessed the situation on the ground in rural
Maharashtra with regard to healthcare delivery specific to
maternity services. We focused on the availability of iron
supplements and emergency obstetric services in the public
This study was conducted during the year 2006 in Ahmednagar
district in the state of Maharashtra in western India. The
district has 14 blocks (including one tribal block) and is
covered by 96 primary health centres (PHCs). Using a
stratified random method, one PHC in each block was selected
for the study.
Three questionnaires were used to collect data. The
questionnaires were designed in the format prescribed under
the Right to Information Act (RTI), Government of India, 2005
in the local language. The first one for the PHCs was tested
by sending it to 3 PHCs. It was then sent to the 14 selected
PHCs. This questionnaire sought information regarding the
number of deliveries occurring in different settings (home,
PHC, private sector and others) in the PHC area, the opening
balance of iron supplements available in stock in the PHC on 1
January 2006, and the monthly demand, supply and utilization
of iron supplements at the PHC. The second questionnaire was
sent to the district health officer (DHO), Ahmednagar.
Information was sought regarding the opening balance of iron
supplements, monthly demand to the State/Centre, and iron
supply received and distributed to PHCs during the year 2006.
The third questionnaire was sent to 3 of the 14 rural
hospitals selected randomly. This sought information regarding
the number of caesarean sections done during 2006 to ascertain
the availability of emergency obstetric services.
Information was received from all the PHCs, the 3 rural
hospitals and the DHO in the month of March 2007. The data
were then collated and analysed.
Three of the 14 PHCs (21%) had no iron supplements available
during the entire year, whereas 4, 3 and 4 PHCs had iron
supplements available for 1–4 months, 5–8 months and 9–11
months, respectively. None of the PHCs had iron supplements
available during the entire year.
The opening balance of iron supplements available in each
PHC equals its total utilization during the year 2006. No PHC
received any supply of iron supplements from the DHO in 2006
in spite of repeated demands. The reply received from the DHO
admitted to a shortfall of iron supplements in the district
during this period.
Information regarding monthly demand, supply and
distribution of iron supplies was not provided by the DHO.
Instead, the DHO explained that ‘there was a shortage of iron
supplements in the district and efforts have been taken to
follow the issue at higher levels, however with no gains so
There were no caesarean sections done in any of the
selected rural hospitals (Jamkhed, Takli Dhokeshwar and Rahata)
during 2006. The proportion of deliveries that occurred in
PHCs and subcentres, at home and at private facilities was
1:1.5:5. The average number of deliveries that occurred in
other places (i.e. hospitals of non-governmental
organizations, trusts, teaching institutes, or rural/civil
hospitals) was <1%.
The majority of deliveries occurred in the private sector
in all PHC areas, with the exception of Ladagon, in the tribal
block. Six areas (Belapure, Chichondi, Chapadgaon, Baragaon,
Chanda and Kolhar) had exceptionally low numbers of deliveries
occurring in PHCs.
Our study shows the lack of availability of iron supplements
and emergency obstetric care services in the public health
system in Ahmednagar district during 2006, a situation which,
following further investigation, we know persisted till June
2007. This situation is unacceptable because the prevention of
undesirable complications of anaemia in pregnancy is
The government’s promise to provide at least 3 ANC
check-ups to 90% of pregnant women by 2007 is justified. The
aim of 3 ANC check-ups is to screen high risk pregnancies
(which include anaemia), allowing early detection and
prevention of complications during pregnancy. The government
has assigned the task of registration and conduct of ANC to
auxiliary nurse midwives (ANMs) at each PHC and its subcentres.
This includes the provision of 100 tablets of ferrous sulphate
and folic acid (60 mg of elemental iron and 500 µg folate) to
each non-anaemic pregnant woman as prophylaxis and a higher
number of tablets to those who are anaemic. However, there was
no supply of iron supplements to the DHO and hence the PHCs
had to manage with the past year’s balance stock during 2006.
While complete ANC coverage remains a far goal, it is
debatable whether its achievement will make any dent in the
prevention/management of anaemia during pregnancy, the second
largest cause of maternal deaths in India. It is unrealistic
to expect any results from the ANM when supplies are
non-existent at the district headquarters itself.
In view of the ample scientific evidence and concurrent
policies for iron supplementation during pregnancy together
with adequate funding for the programme, this situation points
to a management failure of the public sector to provide ANC.
It is particularly deplorable because several initiatives such
as the White Ribbon Alliance have been taken to make
In addition, people’s perceptions regarding ANC need to be
addressed. ANC tends to be perceived as unnecessary unless
there are specific problems during pregnancy. For example, 35%
of recently delivered women, who did not receive ANC,
considered ANC as ‘unnecessary or not customary’.6
The high number of institutional deliveries in this study
cannot be correlated to ANC coverage as most women in rural
areas present to a facility at the onset of labour and because
the proportion of deliveries in the private sector is higher.
This makes the outreach ANC services provided by the
government even more crucial, irrespective of
the ability to afford ANC from the private sector.
Although our results show that the
government target of 65% institutional deliveries is achieved,
the relative proportion of deliveries occurring in the private
sector is 5 times that in the public sector. This is due to
the failure of the public sector, which is not equipped to
provide emergency obstetric care services. Indeed, no public
health outlet included in our study provided emergency
obstetric care. The only public sector option for emergency
obstetric care is the district hospital which, due to the
distance and time required for transportation, does not serve
the purpose in an emergency. Hence, patients are forced to use
the private sector. The government started the Janani
Suraksha Yojana over 2 years ago; this provides financial
support to women below the poverty line (BPL) who are referred
to private prac-titioners from PHCs for emergency obstetric
care. This scheme contributes a meagre sum of Rs 1500 per
woman, whereas a caesarean section costs about Rs 8000, and
much more if complications occur. This results in high
out-of-pocket expenditure leading to indebtedness and
Even in the private sector, which shows a
high number of institutional deliveries in our study, there is
an absence of any regulatory mechanism to control cost as well
as the quality of care.
Many studies have suggested that
interventions to reduce malnutrition and anaemia must begin
long before girls reach the reproductive age. A paradigm shift
from maternal and child health to reproductive and child
health has been widely advocated. This includes the care of
adolescents. In the face of problems such as early marriage,
the unmet need for contraception, and the high prevalence of
anaemia in adolescents, the Kishori Shakti Yojana on
adolescent health appears to be a hopeful development. This
includes provision of iron supplementation to anaemic
adolescents by anganwadi workers. However, the
inadequate supply of iron supplements for pregnant women
suggests that there remains little hope for an adequate supply
The failure of the public sector in providing essential
healthcare also implies that the poor who can ill afford
private maternity care are less likely than others to avail of
institutional delivery facilities. The underutilization of the
public health system is due to the dissatisfaction with it in the absence of
essential and basic supplies such as iron and emergency
obstetric care services. The promises made to provide
continuous essential obstetric care at the PHC level and
emergency obstetric care at the rural hospital level, together
with reforms of the health system at the launch of the NRHM in
Maharashtra in April 2006 demand a serious re-assessment in
view of the situation in the field.
The ground realities in the area of
reproductive health services show persisting shortage of
essential supplies for a significant period. The utilization
of PHCs for maternity care is negligible and points to
dissatisfaction with the public health system in the
community. The absence of emergency obstetric care services in
the public sector in rural areas forces the use of unregulated
private medical facilities. Unless these issues are addressed
effectively, no concurrent programme can make a successful
move towards safe motherhood.
We acknowledge the valuable support
received from Dr N. F. Mistry, Director and Trustee,
Foundation for Research in Community Health, Pune.
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