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Maternal death audit unravels the other side of a deafening silence

Priyanka Khanna

Vaishali, Bihar, 18 June 2008: Married at 16, dead at 17 is the story of Rani’s brief existence.

One of eight children, Rani’s parents had made her drop out of school to take care of her younger siblings when she was just 13. A year ago, they got her married to a 19-year-old boy who had also not completed school.

When Rani conceived her first child, she was asked by the local health worker to go in for free antenatal check-ups at the health centre nearby. Rani was too shy to venture out of her house.

The petite girl went into labour in the wee hours of the morning, but her under-developed body could not survive the birth of her first child. Rani delivered her baby at home with only an unskilled traditional birth attendant by her side.

Immediately after delivery, she began bleeding profusely and having convulsions. Though she lived only five kilometers away from a well-equipped health centre, her family members neither rushed her to the hospital nor called the local health workers who lived a few houses away.

Rani passed away five hours after giving birth to a new life. Rani is one among the 25 women who die every day in the eastern Indian state of Bihar on account of pregnancy-related complications.

With 301 maternal deaths per 100,000 live births, India accounts for more than 15 percent of global maternal and child deaths – most of which could be prevented with access to the right kind of information.

Rani’s death may never have come to light had a local UNICEF-trained youth volunteer not got the wind of it.

The underlying contributor to Rani’s death, which was largely due to the overall low socio-economic status of women accentuated by the myths and misconceptions of her family members, would never have emerged had trained personnel not gone to her house and enquired about what transpired before she died.

What they found was that when Rani went into labour, her husband had only Rs. 500/- on him. Though he was aware of the importance of institutional delivery and his own sister had delivered recently in a health centre, he had not kept any money aside in preparation of the birth of his own child.

Also, as it was very early in the morning, he decided to call the traditional birth attendant and not the government health worker termed ASHA who would have insisted that the delivery take place in hospital.

© N. Chuni /UNICEF /2008
Rani's child looks on angrily even as his aging grandmother breaks down during MAPEDIR enquiry.

Once the baby was delivered, the family members did not realize how bad Rani’s condition was and that she needed immediate medical attention. When she began having convulsions, they took it as a sign that she was possessed and they went to call an Ojha.

Such detailed enquiries give an important insight into the medico-socio-economic reasons for the high number of maternal deaths in India. Called the Maternal and Perinatal Death Inquiry and Response, or MAPEDIR, an initiative to mobilize communities and create awareness to avert maternal mortality in India. 

Developed and implemented with Johns Hopkins University in the United States, MAPEDIR uses what is called the ‘verbal autopsy method’ to gain insight from people in communities who have first hand experience with the tragedy of maternal death.

Equipped with a detailed MAPEDIR questionnaire, UNICEF-trained volunteers in Bihar’s Vaishali district conduct one-on-one interviews with family members and health care workers.

“The approach seeks to identify community factors, and gaps and failures in the health care system, only in view of taking positive action toward improvement – never to provide the basis for legal action, punishment or blame," says Bijaya Rajbhandari, State Representative, UNICEF Office for Bihar.

The data collected at these interviews is analyzed and presented to local communities in order to galvanize them into coming up with effective local interventions and to advocate for improved services.

UNICEF trained volunteers encourage community members and health care workers to help others by thoroughly documenting and reporting all deaths. This grassroots approach also aims to embolden women to assess the quality of their obstetric care.

The findings will allow communities, local governments and non-governmental organizations to take definitive action against the documented factors contributing to maternal mortality.

India’s national Ministry of Health and Family Welfare as well as the Bihar Government’s Health Department have already stressed the need for skilled birth attendants and adequately equipped hospitals. Despite this guidance, India continues to lose women to preventable maternal death.

MAPEDIR aims to gather the missing information/link to unfold the mystery of death and to improve the health system response.

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