Emergence of the issue
During the initial years, a little attention was paid to Maternal and child health. Before 1970s, developing countries used approaches concentrating on urban medical centers and use of highly trained personnel and modern technology (Rosenfield & Main, 1985). Later it became more clear that adopting approaches based on Northern systems of medical care , without taking account of contextual circumstances resulted in difficulties to access the health services and other primary health programmes focussing on maternal health. As a consequence to this, a shift can be noticed since 1970’s where the needs and resources were taken into account by the developing nations before formulating policies and programmes.
In 1985, two prominent academicians (Rosenfield and Maine ,1985) wrote highly influenced papers which galvanised interest and putforth the issue of maternal mortality on an international health policy agenda. The argument focus was to highlight ‘M’ in MCH as most of the programmes were child oriented and assumptions were made that” whatever is god for the child is good for the mother” (Rosenfield & Maine 1985). Safe Motherhood Conference in Kenya was the first international conference directed towards maternal mortality which eventually led to the launch of the Safe Motherhood Initiative. With maternal mortality becoming the focus of health service research (Brouwere et al 1988) a shift was observed in the theme of Reproductive Health. Role of women was not merely confined to child- bearing and child- rearing but had gone beyond that. This phenomenon was further catalysed by the 1994 International Conference on Population and Development (ICPD), in Cairo. International conferences, such as the Cairo Programme of Action, were held, and the goal to decline the maternal mortality rates was set (AbouZahr & Wardlaw 2001). The approach to improving maternal health changed as well as during the International Conference on Population and Development in 1994 the focus on maternal health transferred from a demographically driven approach to a human rights approach (Potter et. al. 2008). Later, with Millennium Development goals the focus of maternal mortality became a high priority. Millinnium development goals give a holistic approach in improving women’s overall well being. Here is a small brief about how the goals are oriented and directed towards the improvement of women’s health.
In 2000 the Millennium Development Goals (MDG’s) were adopted by the international community. These goals aim to encourage development by giving strength, to back the social and economic conditions in the world’s poorest countries. United Nations International Development Goal 5 emphasizes to “Improve Maternal Health” and the reduction of maternal mortality was adopted by the International Monetary Fund (IMF), the World Bank (WB), Organisation for Economic Cooperation and Development (OECD). It was supported by 149 heads of state at the Millennium Summit in 2000 (AbouZahr & Wardlaw 2001). This Millennium Development Goal (MDG) for 2015 includes target 5.A: “Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio” and Target 5.B: Achieve, by 2015, universal access to reproductive health (UN, 2012).This development goal is strongly interlinked with other development goals namely, MDG1 “Eradicate extreme poverty and hunger”, MDG3 “Promote gender equality and empower women”, MDG4 “Reduce child mortality rates” and MDG6 “Combat HIV/Aids, malaria and other diseases”.
Maternal Health in Developing countries (previous lit review)
Globally, an estimated 287 000 maternal deaths occurred in 2010, a 47% decline from levels of 1990, (WHO 2010) and that 88-98% of these deaths are avoidable (WHO, 1986). Despite this decline, developing countries continued to account for 99% of the deaths. Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of the global burden (245 000 maternal deaths) in 2010. The global MMR in 2010 was 210 maternal deaths per 100 000 live births, down from 400 maternal deaths per 100 000 live births in 1990.
In sub-Saharan Africa, a number of countries have halved their levels of maternal mortality since 1990. In other regions, including Asia and North Africa, even greater headway has been made. However, between 1990 and 2010, the global maternal mortality ratio (i.e. the number of maternal deaths per 100 000 live births) declined by only 3.1% per year. This is far from the annual decline of 5.5% required to achieve MDG5.
The MMR in developing regions (240) was 15 times higher than in developed regions (16). Sub-Saharan Africa had the highest MMR at 500 maternal deaths per 100 000 live births, while Eastern Asia had the lowest among MDG developing regions, at 37 maternal deaths per 100 000 live births. The MMRs of the remaining MDG developing regions, in descending order of maternal deaths per 100 000 live births are Southern Asia (220), Oceania (200), South-eastern Asia (150), Latin America and the Caribbean (80), Northern Africa (78), Western Asia (71) and the Caucasus and Central Asia (46).
At the country level, two countries account for a third of global maternal deaths: India at 19% (56 000) and Nigeria at 14% (40 000). Apart from the above two countries other eight comprise of 60 per cent of the global maternal deaths: India (56,000), Nigeria (40,000), Democratic Republic of the Congo (15,000), Pakistan (12,000), Sudan (10,000), Indonesia (9,600), Ethiopia (9,000), United Republic of Tanzania (8,500), Bangladesh (7,200) and Afghanistan (6,400) (WHO,2010). Full scale of the burden is not acquired and confined by the numbers of deaths alone. Much less is known about the scale of ill health resulting from pregnancy complications.
Maternal deaths in developing nations are mainly from obstetric causes (OC) -bleeding, hypertensive disease, infection, obstructed labour and unsafe abortion (Khan et al., 2006). Life threatening complications are experienced in 15% of pregnant women, although some form of obstetric problem occurs in over 40% of pregnancies (WHO, 1994). It is estimated that over 300 million women suffer ill health as a consequence of pregnancy or childbirth, with 20 million new cases occurring annually (WHO, 2005). For instance, 12% of women who survive severe bleeding will suffer severe anaemia (AbouZahr, 2003). Two million women are thought to live with debilitating complication like obstetric fistula as a result of obstructed labour (Lewis and de Bernis, 2006). Depression is thought to appear during pregnancy in between 6% and 25% of women in developing countries (WHO and UNFPA, 2009).
Maternal health in Indian context
Before reflecting on the Maternal Health Care in Indian Context, a glimpse on the explanation of how the maternal health services are perceived in this study and what are the essential components that are taken into account when one mentions- Ante-Natal Care; Post-Natal Care and During delivery Care.
Maternal Health Care Services
Antenatal and Postnatal Care
Antenatal care is the ‘care before birth’ to promote the well-being of mother and fetus, and is essential to reduce maternal morbidity and mortality, low-weight births and perinatal mortality [WHO 1994]. Antenatal care services (ANC), a major component of the maternal and child health programme, is said to have a constructive effect on family planning, especially among younger women (Mishra et al 1998). However, the content and quality of antenatal care and the availability of effective referral and essential obstetric care are important for antenatal care to be effective [WHO 2005].
According to, Indian Public Health Standards (2006) in India ANC services starts from the period of getting an early registration within the first trimester (before 12th week of pregnancy). However if woman comes late in her pregnancy for registration, then the care is provided according to gestational age. Following the registration, a minimum three antenatal checkups  are recommended. Associated services like general examination such as height, weight, B.P., anaemia, abdominal examination, breast examination, Folic Acid Supplementation in first trimester, Iron & Folic Acid Supplementation from 12 weeks, tetanus toxoid injection, treatment of anaemia etc., (as per the Guidelines for Antenatal care and Skilled Attendance at Birth by ANMs and LHVs).Minimum laboratory investigations like haemoglobin estimation, urine for albumin and sugar.
Postpartum care encompasses management of the mother, newborn, and infant during the postpartal period. This period usually is considered to be the first few days after delivery, but technically it includes the six-week period after childbirth up to the mother’s postpartum checkup with her health care provider. The postnatal period is usually a neglected period, despite the fact that the majority of maternal and newborn deaths occur within the first week of the postnatal period. The PNC services provided at the community level include counseling on family planning, breast feeding practices, nutrition, management of neo-natal hypothermia, early detection of postpartum complications and referral for such problems. The higher-level health care facilities are intended to provide these services as well as take care of post delivery complications. Postnatal care therefore includes a minimum of 2 postpartum home visits  followed by an initiation of early breast-feeding within half-hour of birth. Counselling on diet, hygiene and essential new born care (As per Guidelines of GOI on Essential newborn care) and STI/RTI and HIV/AIDS.
Health Care Services for Child Delivery
There are two aspects of the delivery services considered — one being delivery at home or institutional health care facility and the other being the presence of a trained personnel to assist the delivery. There are several reasons behind the preferences of opting one over the other. There are vast reasons ranging from cultural, social, economic factors to influence this decision of delivery.
Quality of Health (Reproductive) Services
The network of government services in India is very large but the quality of these services leaves much to be desired. Although there is a large and thriving private health sector in India, the primary health and reproductive health care needs of the masses, especially in rural areas, are expected to be provided by the public facilities, mostly run by the state governments. However, due to various inefficiencies in the public health care delivery system, even the minimum facilities are not often made available to the target groups in the population.
Status of women
According to the recent Human Development Report (2011), India stands at 134th rank of total 187 countries, which further takes into account the sex ratio of 914 females for 1000 males (Census, 2011). The numbers reflect the gender bias towards men in Indian context and the cultural preference of male over female, a significant reason of unbalanced ratio factoring men (Patel, 2002). In a country like India, a woman’s subordination to that of a man is quite prevalent as she is experiences discrimination and humiliation at different levels. It is through her lifetime that the autonomy to take decision regarding different issues manifests an inequality and inferiority in prevailing patriarchal society. Women are generally caught between two extremes- Right to life VS Right to Choice. Women suffer many forms of gender violence, such as child marriages, forced marriages and other physical, psychological and sexual abuses. Because formal and informal justice systems support patriarchal values and ways of life, women and children who are abused have a very little chance of turning around. This, similar situation can be noticed when a woman has to make decision during her pregnancy from the time of conceiving till the time of delivery.
Emergence of maternal health issues- Indian context (A paradigm shift from family welfare programme to Reproductive Health)
In India, to fulfill the basic health facilities and services, State has been taking the primary responsibility by laying down provisions, priorities and directions in its 5 year plan since 1951.
There is no denying the fact that health status and standards in India have significantly improved over the years since independence. With its health policies and programmes it acted as a strong pillar in reaching out to the marginalized and weaker section of the society. India, through its health policy shifted the focus from comprehensive universal care system to selective and targeted programmes. This is very well evident in respect to maternal health in India, with various implementations of programmes at different intervals.
Reproductive health concerns to a large extent surrounds with restricted parameters, which tend to look women’s health with a myopic lense of patriarchal dominant society. These parameters put a boundary around our understanding of women’s reproductive health and reduce the same to issues in regard with maternal and child health. Understanding women’s health is not merely constrained to the concept of reproductive health nor is the concept of reproductive health is to be associated with women. Both men and women are inextricable to the important concept of Reproductive Health. In India, the role of the husband has been noted in decisions mainly confined to the use of contraception and expenditure for health care (Barnett 1998; Sharma and Sharma 1993).
In 1960’s and early 1970s , India’s programmes for maternal and child health and family planning were mostly vertical which did not take an account of needs of community, outreach programmes and facilities. In 1992, India launched the Child Survival and Safe Motherhood (CSSM) Programme by bringing together interventions for child survival and maternal health.
In 1997, Reproductive and Child Health Program was launched as the national policy of the government of India. This program was based on the existing Safe Motherhood Program and connected maternal and child health with the strengthening of referral systems for obstetric care. RCH –II followed RCH –I in the year 2005 with the objectives of reducing maternal mortality. The focus on reproductive and child health shifted to births in institutions and emergency obstetric care as the key strategy for reduction of the maternal mortality rate. According to National Institute of Health and Family Welfare, the official RCH programmes include the conventional maternal and child health services including immunisation of children and contraceptive services to couples, treatment of RTIs and STDs, provision of reproductive health education and services for adolescent boys and girls, safe abortion and pregnancy related issues . In the same year the National Rural Health Mission was launched by the government to strengthen the existing health services. Essential components of NRHM were inclusion of training local residents as Accredited Social Health Activists (ASHA) and the Janani Surakshay Yojana (motherhood protection program).
Under international law, the government of India bears a legal obligation to ensure that women do not die or suffer complications as a result of preventable pregnancy-related causes. (Centre for Reproductive Rights, 2008). Followed by the Safe Motherhood Initiatives in 1987 and the International Conference on Population and Development in 1994, a global agreement on the concerns of maternal and child health was re-emphasized in 2000 as the Millennium Development Goals (MDGs). The MDG 4  and 5  aim for a 75% reduction (from the level of 1990) in child and maternal mortality by 2015 (Lozano R, 2011). As a signatory of Millennium Development Goals set by member states of the United Nations, India is accounted to reduce MMR to 109 per one lakh live births by 2015. Even after a drastic decline of 38 per cent in maternal deaths since 1990, India’s MMR is 212 per one lakh live births which remain far from the sight of actual target (SRS, 2011). There is an uneven distribution of maternal mortality within the country which widely vary across Indian states (RGI , 2011)
SOURCE: SRS 2011
The fragmented distribution of MMR within the country in the study (Kumar & Prakash, 2011) shows the inequities in utilisation of maternal and child health care services. The evidence elucidate that the poor, a majority of those who are socially marginalized, get the least access to preventive and curative health services. (Sharma et al 2002) .Women belonging to the scheduled castes and scheduled tribes have much poorer access to health care compared with men and women belonging to the other castes and classes. (Baru R, Acharya A, Acharya S et al., 2010). In addition, the health-care services are suboptimal in rural areas, 8 where majority of people in India reside. India has one of the most fragmented and commercialized health-care systems in the world, where world-class care is greatly outweighed by unregulated poor-quality health services.
International Institute for Population Sciences (IIPS), using the India’s 2005-06 National Family Health Survey (NFHS-3) recently analysed the health and living conditions in eight large Indian cities (Chennai, Delhi, Hyderabad, Indore, Kolkata, Meerut, Mumbai, and Nagpur). The report points out to some crucial findings about the inadequate maternal health care utilization among these eight large urban cities. Although the utilization of antenatal care services differs substantially among the cities and between their slum and non-slum areas, in almost all cases poor women are the least likely to receive antenatal care services. Only 34.5% of mothers in the urban poor areas consumed iron and folic acid  for 90 days or more when they were pregnant with their last child. The report reflects that the home deliveries in urban area are still around 32.6% and among urban poor is 56%. NFHS-3 data clearly shows the births in health facilities in Urban area is 67.4%, whereas among the urban poor is mere 44%. Institutional deliveries though have increased by 7 percentage points between NFHS-2 and NFHS-3. Nonetheless, more than half the deliveries still take place at home; half are not assisted by health personnel. The majority of mothers with a recent delivery did not receive any postnatal care. The utilization of delivery and postnatal services were lowest among poor women in all cities except Chennai. The differences are particularly striking in Meerut and Delhi, where less than 4 in 10 poor women received a postnatal check-up, less than one-quarter of poor women had health personnel assisting at the delivery, and less than 2 in 10 poor women delivered in a health facility.
The contrast can be seen with low penetration of the institutional delivery being a major cause for not implementing or bringing changes. Despite improvements in the provision of maternal health care, at the current rate of change at no more than one percentage point a year, women’s reproductive health continue to suffer well into this century.
There are number of health care programmes provided by government in regard with women in rural and urban areas. Numerous facilities are provided through the policies, schemes and programmes like- National Rural Health Mission, Reproductive Health care, Integrated Child Development Services, National Mental Health Programme and so on but significant gap is observed between health programmes design and its implementation as experience by women users. It is an unpalatable fact that “Child bearing in India, for the majority of women is more health hazard than natural function”, Batliwala.S (1995) points out that the National Health System merely views women as mothers and reproducers and it is because of this fact that not much emphasis is paid to the overall health care of women.
“Primary health care facilities have not grown in proportion to the explosive growth of urban population, especially for the poor. Also, health facilities may not be in physical proximity to urban slum neighbourhoods. Among the urban poor in India, only 25 percent of mothers receive complete antenatal care during pregnancy (at least three ANC visits, iron and folic acid tablets for at least three months, and at least two tetanus toxoid injections). Among the urban poor, almost three-quarters of babies are delivered at home.” (Agarwal et al., 2007)
The causes of maternal deaths depicts that most of the deaths in India are pregnancy and childbirth related. Since majority of maternal deaths occur during and soon after delivery, it reflects on the fact that though the coverage of health services in spreading among the rural and urban areas of the country but not much emphasis is laid on the proper utilisation of such services. The terms utilisation and coverage are often overlapped and used in the same context. Utilisation refers only to service and its measurement is only indirectly related to the size of the target population; on the other hand, coverage expresses a relationship between the services and the target population. For example, a high utilisation of service facilities does not necessarily imply satisfactory coverage and could in fact imply the contrary ( Tanahashi 1978)
The slow and staggering scale of maternal mortality clearly indicates to the incompetence by the Indian government to protect women’s reproductive rights and abide by the international laws and policies.
This picture of “health for all” and “reaching out to all with strong policies and programmes”, contrasts rather sharply with the failure of schemes and the under investments made in health sector. Though on papers India reflects concrete and genuine policies that reach out to the poorest of poor but the fact somehow is deplorable. Within this large segment of our population specially the Women and children have been left outside the growth process and are the easy victims of the (denied) health care system in India.
Emergence of Urbanisation
It is for the first time since Independence, the absolute increase in population is more in urban areas that in rural areas. Urbanisation can result from (1) natural increasing population (2) net migration from rural areas to urban areas and (3) reclassification of villages as towns largely because of changes in the nature of economic activities. Level of urbanization increased from 27.81% in 2001 Census to 31.16% in 2011 Census. With urban population crossing the rural, increasing urban births is unavoidable. With the augment in urban population and continued migration from rural to urban areas, the share of urban population to total population, has grown from 17.3 per cent in 1951 to 31.16 per cent in 2011. India is expected to reach more than 550 million urban population by 2030. As India is becoming increasingly urban, there is also an increase in the number of urban poor. As per the NSSO survey reports there are over 80million poor living in the cities and towns of India. Over the past three decades (1973-2004), the numbers of the urban poor have increased by 34.4 per cent and the shares of the urban poor in the total from 18.7 per cent in 1973 to 26.8 per cent in 2004-05. In comparison the numbers of the rural poor have registered a 15.5 per cent decline over this period. In addition, about 40-45 million persons are on the border line of poverty ( NSSO, GOI 2007)
According to Planning Commission Report (2012), “the urban poverty manifests in the form of inadequate provision of housing and shelter, water, sanitation, health, education, social security and livelihoods along with special needs of vulnerable groups like women, children, differently abled and aged people. Most of the poor are involved in informal sector activities where there is constant threat of eviction, removal, confiscation of goods and almost non-existent social security cover. Even when segments of the urban population are not income-poor, they face deprivation in terms of lack of access to sanitary living conditions, and their well-being is hampered by discrimination, social exclusion, crime, and violence, insecurity of tenure, hazardous environmental conditions and lack of voice in governance.”
Moreover the quality of life and access to basic services by India’s urban poor is far from satisfactory (Planning Commission, 2011).
Defining Urban Poor
According to a recent report of an expert group set up by the Planning Commission’s perspective planning division submitted a detailed methodology to identify below poverty line (BPL) households in urban areas. It is using this recent report the definition of urban poor is considered in the research study. According to the group’s report, income-based criteria will not be used to identify the poor. Rather, it has created a simple and transparent formula where households will be either automatically included or excluded from the list.
Stage 1: Automatic Exclusion: If the number of dwelling rooms exclusively in possession of the household is 4 and above (dwelling rooms as specified in the Report) that household will be excluded. Secondly,the household possessing any one of the assets, i.e., ‘4 wheeler motorized vehicle’, ‘AC Set’ and ‘computer or laptop with internet’ will also be excluded. Besides the households possessing any three of the following four assets, i.e., refrigerator, telephone (landline), washing machine, two wheeler motorized vehicle will also be excluded.
Stage 2: Automatic Inclusion: households facing various kinds of deprivations and vulnerabilities viz. residential, social and occupational vulnerabilities would be automatically included in the BPL List.
i. Under residential vulnerability, If the household is ‘houseless’ as defined in the Report or the household has a house with roof and wall made of plastic/polythene or the household having only one room or less with the material of wall being grass, thatch, bamboo, mud, un-burnt brick or wood and the material of roof being grass, thatch, bamboo, wood or mud, then that will be automatically included.
ii. Under occupational vulnerability, the household having no income from any source; any household member (including children) engaged in a vulnerable occupation like beggar/rag picker, domestic worker (who are actually paid wages) and sweeper/sanitation worker /mali); and all earning adult members in a household are daily wagers or irregular wagers, then that household should be automatically included.
1. Household having a house of four rooms
2.Households possessing any one of the following assets: four wheeler motorised vehicle, air conditioner, computer or laptop with Internet
3. Households possessing any three of these: refrigerator, telephone (land-line), washing machine, two-wheeler motorised vehicle.
b) Occupational vulnerability
i. If the household has no income from any source, then that household will be automatically included.
ii. Any household member (including children) who is engaged in a vulnerable occupation like beggar/rag picker, domestic worker (who are actually paid wages) and sweeper/sanitation worker /mali) should be automatically included.
iii. If all earning adult members in a household are daily wagers or irregular wagers, then that household should be automatically included.
MAHARASHTRA- Urban Poor & Utilisation of Maternal health services
In this context, Maharashtra continues to be the second most populous state in the country with almost 112.4 million people residing here (Census 2011). Maharashtra has the highest urban poor population in India and continues to grow rapidly. The slum population of urban Maharashtra is 27% of the total, where the contribution of Mumbai alone is 54% of the total slum population.The urban poor rarely benefit from the facilities in urban areas and are as deprived as those in the rural areas. The health of the slum communities is considerably worse off than the non poor in urban areas and is comparable to the rural figures (NFHS 3).
UTILISATION OF MATERNAL HEALTH SERVICES IN MAHARSHTRA
A reanalysis of key results from NFHS III (2005-2006) for the state of Maharashtra by UHRC reflect prominent gaps in the health status of urban poor women among the rest. The prevalence of Anaemia among women in Urban Maharashtra is 52.4 percent (Fig 4). There is substantial evidence supporting the fact that with iron deficiency in a woman increases the risk of preterm delivery and subsequent low birth weight (Viteri 1994 &Allen 2000). To add on to this, mere 15.9 per cent of women receive adequate Iron Folic Supplements. There is also a marked difference in the mothers who received complete Ante-natal Care, dropping to 10.2 per cent in NFHS-3 from 24.8 per cent in NFHS-2 among urban poor. This reflects on the inadequate utilisation of “complete” ANC by the urban poor women in course of her pregnancy. A total of 58.4 per cent (Fig 6) of urban poor were reported to be delivering their children in institutional facility which is still is a small number in an urban area where the extent of awareness and access is more if compared to rural. Though 89 per cent of the urban non-poor avail the health facility, it reflects on a vast difference marked by inequality in urban structure of Maharashtra.
A baseline survey conducted in the Urban Slums of Maharashtra gives a comprehensible representation of the Maternal and Neonatal Health status. The study covers seven urban slums of Mumbai, Navi Mumbai, Pune, Nagpur, Malegaon, Sholapur and Nanded. A total of 3284 mothers who delivered a live birth during the year of 2007 were covered. The survey highlights deplorable situation of maternal health facilities. As noted (Patil and Asif 2007) , not only there was late or no ANC registration but the prevalence of home deliveries, delay of breast feeding, lack of quality to care, negative attitude towards public health facilities, women’s suppressed autonomy etc were some of the main causes of poor mechanism in providing and receiving maternal health care services. It is evident from the study that the urban poor having the literacy level of 80 per cent were still unaware of complete and full-fledged information regarding all the facilities ranging from ANC to Post natal care.
The study gives a framework of how the health facilities are being utilised by urban poor women. On one hand with the booming economy the urban areas and people residing are flourishing in all spheres but at the same time, there is a sharp disparity that exists between the living conditions of the ‘urban poor’ and the ‘better-off population’ in urban areas in India.
Profile of the respondents
20% were illiterate
91% mother were not working
99% of the spouses of respondents were working
41% were using public toilets and 33 percent had their private toilet facility
7% households had a monthly income of less than Rs. 1000
80% households had a monthly income of Rs. 1000 to 5000
Urban health facilities were not affordable for the slum dwellers