Maternal health and health care in Madhya Pradesh state of India an exploration using a human rights lens

Sammanfattning: Pregnancy and motherhood are natural processes in the lives of women of reproductive age. These processes are generally considered to be positive and fulfilling experiences. However, for various reasons, many women end up dying as a result of these processes. Improving maternal health and reducing maternal mortality are accepted as human rights challenges and prioritized in several international declarations and national policies. However, progress in achieving these objectives still remains poor.This thesis aims to explore the maternal health and healthcare in the Indian state of Madhya Pradesh through a human rights lens. A human rights lens provides a framework to study various aspects of the problem of maternal health from a human rights perspective. It helps in highlighting the gaps and challenges related to political priority, sociocultural, economic and individual-level factors and the availability, accessibility, acceptability and quality of maternal healthcare services. A combination of quantitative and qualitative research methodologies was applied in four sub-studies conducted in Madhya Pradesh. The specific objectives were: to investigate, by using John W. Kingdon’s multiple-streams model of agenda setting, why and how maternal health became a political priority in the state (Paper I); to estimate the effects of individual-, community- and district-level characteristics on the utilization of maternal health services with special reference to antenatal care, skilled attendance at delivery and post-natal care (Paper II); to analyse sociocultural and service delivery related dimensions of maternal deaths in rural central India through a human rights lens (Paper III); and to evaluate the technical efficiency of the public district hospitals using data envelopment analysis (Paper IV).The findings of the first qualitative study indicated that various developments at international, national and state level brought the issue of maternal health to the priority political agenda in Madhya Pradesh state. This resulted in the introduction of new policies and programmes and more resources were allocated for improving maternal health. However, several challenges still remain in ensuring proper implementation of these programmes and policies. The quantitative study on factors affecting the use of maternal health services revealed that 61.7% of women used antenatal care at least once, 49.8% of women used skilled attendance at delivery and 37.4% of women used post-natal care during their most recent pregnancy. The household’s socio-economic status and mother’s education emerged as the most important factors associated with the use of antenatal care and skilled attendance at delivery. Delivery by skilled personnel and the use of antenatal care were the most important factors in the use of post-natal care. This study highlighted the need to identify and focus on community- and district-level intervention along with addressing the individual-level factors.The findings of the third qualitative sub-study revealed that all pregnant women in the study tried to access medical assistance for obstetric complications but various factors delayed appropriate care. The underestimation of complication symptoms by family members, gender inequity and the negative perceptions regarding delivery services deferred decisions to seek care. Transportation problems and care seeking at multiple facilities also constrained timely reaching of appropriate health facilities. Negligence by health staff in providing care, and unavailability of blood and emergency obstetric care services, delayed the receiving of adequate care after reaching a health facility. This study indicates that normative elements of a human rights approach to maternal health, i.e. availability, accessibility, acceptability and quality, were not fully upheld. The deceased women and their relatives were unable to claim their entitlements and the duty bearers could not meet their obligations despite their conscious efforts to improve maternal health. In the last study, the results of data envelopment analysis revealed that half of the district hospitals (20) in the study were operating inefficiently.This research establishes a need to give special attention to addressing challenges in the maternal health programmes at the implementation level as well as tackling the social determinants of maternal health. In order to increase the utilization of maternal health services in the state, the need to identify and focus on community- and district- as well as individual level interventions is emphasized. In order to prevent maternal deaths, a need for further concentrated efforts is underlined with a view to honouring human rights elements of maternal health by better community education, women’s empowerment and health system strengthening with the provision of appropriate and timely services including emergency obstetric care of good quality. It also highlights a need to identify the causes of the observed inefficiencies and to take appropriate measures to increase the efficiency of district hospitals.