Going ‘Beyond the Numbers’: Maternal Death Reviews in India

ABSTRACT

This essay discusses the Indian government’s implementation of maternal death reviews (MDR) across the country in response to a global WHO strategy called ‘Beyond the Numbers.’ India’s MDR process attempts to better count and assess maternal deaths across the country, yet considerable challenges remain. Existing studies of the MDR process in India still reveal systemic failures including poor quality of obstetric care, as well as omissions or delays of care that are covered up or denied. An ethnographic case study suggests ways that ethnographic sensibilities or techniques could be used to harness community stakeholders or lay perspectives by privileging ambiguity, multiplicity, and conflicting views in order to reveal these systemic omissions or failures of accountability. It concludes by suggesting how ethnographic ways of knowing might elicit lay concerns or critiques that threaten the very medical privileges that the MDR process inadvertently shores up.

KEYWORDS:

• India
• maternal mortality
• reproductive health
• verbal autopsy
• WHO

Acknowledgments

The final version of this article has been benefitted from conversations with audiences at the Seventh European Congress on Tropical Medicine and International Health in Barcelona, Williams College, Goettingen University, and the Fortieth Anniversary Conference of the Society for Medical Anthropology at Yale University. I thank Antonia Foias, Peter Just, Julia Kowalski, Claire Wendland; Patricia Jeffery, Claudia Gras, Cecilia Van Hollen, Arthur Kleinman, and Siobhan Doria for conversations and comments on this essay.

Funding

The research for this essay has been funded by Goettingen University, the Humboldt Foundation, Williams College, and the Harvard Society of Fellows.

Notes

1. Freedman and colleagues (2007:1384) noted: “In short, we know what to do, but how to do it varies by context. Understanding context entails an appreciation of the relation between supply and demand within the district level health system. …”

2. In contrast, in countries with low MMR, high resources, and where most deaths take place in facilities, the WHO (2004) recommends three other methods of MDR: (1) confidential enquiries into maternal death, (2) reviews of severe morbidity or near-misses, and (3) clinical audits.

3. According to the WHO (2012) the leading causes of death in India are ischemic heart disease, chronic obstructive pulmonary disease, stroke, diarrheal disease, lower respiratory infections, preterm birth complication (often related to intrapartum or neonatal complications), tuberculosis, suicide, falls, or road injury.

4. There are notable disadvantages to VA including (1) they are labor-intensive and require skilled field-based personnel as well as physicians or algorithms to asses cause of death, (2) the list of causes of death assessed using VA is smaller than the list found in the International Statistical Classification of Diseases and Related Health Problems, tenth revision, and (3) the quality of the assessment can be influenced by recall bias, social desirability bias, or error, such as when laypeople systematically undercount early maternal deaths from illegitimate or hidden pregnancies (Garenne and Fauveau 2006).

5. After 2006, the Indian government refined its verbal autopsies using a method known as RHIME (Routine, Reliable, Representative, Resampled Household Investigation of Mortality with Medical Evaluation) for the Million Death Study, the largest prospective study of deaths in the world (Jha et al. 2006).

6. According to the 2011 census, Leh was the second largest in area but one of the least populated of India’s 640 plus districts, while Kargil district has a third of the land mass of Leh district but roughly equal population of 140,000 people making it three times as densely populated as Leh district. Freedman and colleagues (2007) defined CeMOC (Comprehensive Emergency Obstetric Care) and BEmOC (Basic Emergency Obstetric Care) as follows: BEmOC includes 6 functions: IV antibiotics, IV anti-convulsants, IV oxytocins, manual removal of placenta, removal of retained uterine products, assisted vaginal delivery. CEmOC includes these six signal functions plus surgery (i.e., cesarean or hysterectomy), and blood transfusions.

7. An Indian Council of Social Science Research (2008) survey of Leh district found that 90% of all children were delivered institutionally, while the government reported the institutional rate of delivery in Leh and Kargil districts as 74% and 45% respectively in 2007 (Government of India 2007a, 2007b).

8. Rajan (2005) reported Leh’s TFR (total fertility rate) as 1.3 and Kargil’s TFR as 3.4 in 2001. CPRs across India’s districts in 2003–2004 are reported by the Indian Institute for Population Sciences: http://www.iipsindia.org/pdf/05_b_13atab13.pdf. Guilmoto and Rajan 2013 as well as Raina 2011 explore the confusion behind the low sex ratios reported in Leh district and elsewhere in Jammu & Kashmir in the 2010 census.

9. In 1989, the state government officially declared eight ST groups including both Buddhists and Muslims (Balti, Bot, Purigpa, Drokpa, Changpa, Beda, Gara, Mon) that confer affirmative action including admission quotas to higher education and government jobs. The Beda, Gara, and Mon are considered ‘backward castes’ as they have traditionally been subject to discrimination by commoners who refused to eat food cooked by these groups or intermarry.

10. As described elsewhere (Gutschow 2004, 2011), Buddhists believe that married women are protected by their husband’s guardian deity (pha lha) if they deliver in their husband’s home, but that they offend their former, natal guardian deity––whose protection they abandon after marriage––if they deliver in their natal household. After marriage, a woman’s menstrual blood or bleeding during pregnancy/childbirth is offensive to the guardian deity of her natal household.

11. The Auxiliary Nurse Midwife (ANM) offers a host of preventative services including family planning, immunization, and counseling that prevent her from attending to her already overscheduled midwifery services, the Accredited Social Health Activist receives no salary but cash transfers for a variety of reproductive services or referrals, and the Anganwadi Worker provides nursery care and food to infants and children.

12. The MDR Guidebook perpetuates the assumption that a pregnant women must have a husband by requiring the label w/o (wife/of), while men have no such epithets.

13. The CDC (2014) stated that “roughly 650 women die each year” in the United States as a result of pregnancy-related complications that occur up to a year after delivery. The category of ‘pregnancy-related complication’ is far broader than a ‘maternal death,’ which only includes deaths that occur within 42 days of termination of pregnancy.

14. The WHO estimates the United States’ MMR to be 28 while the GBD places it one third lower at 18.5, and the GBD estimated India’s MMR to be 281 while the WHO estimated it to be 190 (WHO 2014; Kassebaum et al. 2014). Both studies recognize but do not fully explain the wide uncertainty intervals in MMRs for the United States and India.

Additional information

Funding

The research for this essay has been funded by Goettingen University, the Humboldt Foundation, Williams College, and the Harvard Society of Fellows.

Notes on contributors

Kim Gutschow

Kim Gutschow is a professor at the Center for Modern Indian Studies (CeMIS) and the Institute for Social Anthropology at Goettingen University in Germany as well as a lecturer in the Departments of Anthropology and Religion at Williams College. She is the author of an award-winning ethnography, Being a Buddhist Nun (Harvard University Press, 2004) and more than a dozen articles about reproduction, gender, sexuality, and social power in Buddhist monasticism and Himalayan societies. She is completing a book that compares maternal mortality and the quality of obstetric care in India and the United States.