In one of the worst areas of maternal care in the world, a health advocacy is teaching Indian women the three big factors in maternal deaths and how to assert political and community pressure to avoid them.
Payments demanded by doctors for conducting deliveries of babies after 11 at night at a district public health center in Udaipur, a city in the western Indian state of Rajasthan, came down dramatically around August 2009.
That was after 21 women elected by community members to the local self-government--or panchayat--co-signed a letter to the doctor in charge of the government primary health center. In it they complained about the financial exploitation, scarce staff, absence of facilities and incomplete prenatal care.
Soon after, they met with public health officials who promised to address their complaints, which included demands for more funding.
The women didn't stop there. They began visiting the health center every month to monitor absenteeism among health workers and to ensure that clinicians' demands for special payments be stopped.
In the neighboring state of Gujarat, panchayat and self-help group members of the Panchmahals community tracked the provision of public maternal health services in their respective hamlets.
One investigation found that women in one village did not receive care because a female health worker objected to walking across a muddy area to reach them. The activists then provided a medial official with a list of the women who did not receive any services during their pregnancy or childbirth. After that the government opened a satellite center to serve the previously neglected women.
It's a change that began when the Center for Health Education, Training and Nutritional Awareness, a Gujarat based nongovernmental organization that has been advocating for women and children in Gujarat and Rajasthan for the past three decades began to intervene in June 2007. The goal: to make better maternal care part of local self-government.
To help women of little or no literacy in these areas better understand their legal and practical rights to maternal care the organization produced and distributed a picture book on maternal health entitlements for use in village-level meetings, which were held during their three-year project.
Meetings were also held for community members and service providers to discuss what constituted good maternal healthcare. These meetings also provided a forum for discussing monitoring efforts on the denial of health services and other deficiencies. Panchayat leaders used these information to initiate specific advocacy measures to strengthen health services and enhance accountability.
Before beginning its intervention, CHETNA partnered with six local NGOs that worked in these districts to survey 200 village women. They asked questions about what they knew about the clinical basics of maternal health and their legal rights and entitlements to it.
After these village meetings, the same women were surveyed again. The second round of surveys found huge gains.
They showed that the number of women who knew about the three big delays behind maternal mortality -- delay in identifying complications and taking action, delay in reaching the appropriate facility and delay in treatment at the health facility leading to maternal mortality--increased to 108 from 38.
The number of women who knew about the facilities where they could find maternal health services increased to 152 from 52.
The number of women who knew about the village calendar for providing health services rose to 137 from 47.
Half of all maternal deaths in South Asia occur in five Indian states--Rajasthan, Madhya Pradesh, Uttar Pradesh, Bihar and Orissa.
In Rajasthan the maternal mortality rate of 388 for every 100,000 live births, far exceeds the national average of 254.
This information was shared recently at a meeting organized by the NGO as part of its dissemination efforts to provide inputs to the national Planning Commission as the government prepares a strategic budgeting plan for the next five years.
It was pointed out that an assessment of almost 130 PHCs indicated that pregnant women were not receiving continuous care from early pregnancy through delivery and after.
It also testified to poor facilities, equipment and supplies and said many remote villages remained under-served despite the plethora of government schemes to address these problems.