LEADER ARTICLE
Continuing Casualties: No Woman Should Die Giving Life

''Collateral damage'' — a callous term for the killing of women and children in Iraq as bombs fell indiscriminately in civilian areas and maternity hospitals. In any situation, whether in conflict or otherwise, women and children are the first casualties.
We ''celebrated'' Safe Motherhood Day last week, but India is facing another kind of war, one in which a woman dies every five minutes.
The annual toll is unimaginable at 1,00,000 women dead, 6,00,000 disabled, and an estimated 3,50,000 children orphaned.
These are the stark realities of the life and death struggle women are engaged in during pregnancy, childbirth and post-partum. Any pregnancy or delivery can take a sudden turn for the worse and escalate into a life-threatening emergency. Immediate medical treatment is the only hope. Yet, for far too many poor and marginalised women, help is a distant mirage and death comes veiled in silence.
Maternal deaths have not declined in the last decade and today account for one out of every five deaths to mothers globally. The rate of maternal mortality estimated at 407 per 100,000 live births persists at unacceptably high levels. Stunningly, a woman in India is 40 times more likely to die from maternity complications than a woman in developed countries, such as Japan.
What greater injustice can a woman face than dying as she brings forth life? Sadly, when a woman dies, her newborn baby has six to 10 times greater chance of dying as well. These shocking statistics featured at a conference held a while ago under the aegis of UNICEF and the MacArthur Foundation among others.
Despite huge investments made in deve-loping countries since 1987 when the Safe Motherhood Initiative was launched globally, there are still wide disparities between the rich and poor in the use of safe and life-saving maternity care services. Poor, illiterate women continue to have very limited access to quality services.
Even those living within reach of health facilities, do not always avail of these services when they experience life- threatening emergencies. When they die, no one is held accountable. Safe motherhood has gone beyond being a health issue, it is a fundamental human right for every woman.
What is causing these deaths? A major reason is lack of political will. Health features low down on the political agenda and women''s health even less so. The Centre blames the failure of delivery mechanisms on the states, the states, in turn, say they have no funds. Social factors compound the failures. Rural women do not think they are important enough to deserve the required care — one out of three do not receive any ante-natal check-up.
Unfortunately, those women who do not receive ante-natal care are often the most vulnerable — women who are older, with many children, from scheduled castes/tribes and the poor. Ante-natal check-ups con- ducted by skilled health personnel provide an opportunity to detect and treat medical conditions that can affect adversely the health of the mother and the unborn child.
Second, less than half the deliveries are attended by skilled health personnel and in many remote rural areas this falls to as low as five to 10 per cent.
In Kerala, where the maternal mortality ratio is as low as some of the developed countries, almost all deliveries are conducted by skilled health personnel. However, in many northern states where maternal mortality is at the highest levels, skilled health personnel conduct only one out of three deliveries.
Studies have shown that the majority of women and their family members are unaware of the signs of pregnancy-related complications. Thus, it is not surprising that when a life-threatening emergency occurs, they are caught unprepared. This unprepa-redness leads to delays in seeking and reaching medical care. Kamala, a slum-dweller in a north Indian state, delivered at home.
Within a few hours of delivery, she started bleeding but no one at home recognised that this was abnormal. By the time they realised something was wrong, Kamala was in danger. It was too late. She died a few yards from her home in a rickshaw on way to the hospital.
This is not an isolated incident. Similar scenarios occur every day. It is critical that every pregnant woman and her family have a birth preparedness and complications readiness plan. They need to find out well in advance the closest health facility that has emergency services such as surgery and blood transfusion, identify a source of transport and set aside funds for medical care and transport.
They need to learn the signs of any obstetric emergency that can occur during pregnancy, delivery and following delive-ry — haemorrhage, high fever, convulsions, and labour that lasts more than 12 hours.
For many rural women, health facilities capable of managing emergencies are far from home in the district centre; whereas the closer rural referral units often lack the necessary medical personnel, equipment and supplies required to save lives.
For example, blood supply for transfusions is found only in a few hospitals; in all of India there are a mere 350 certified blood banks. Investing in emergency obstetric care services for rural women will result in large dividends in women''s lives saved.
It is high time we did more for mothers in this country. We all have a role to play, be it the pregnant woman, her family members, the community she lives in, the health providers, NGOs and the government. With increased commitment from all, many maternal deaths can be prevented.