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SAHAYOG works intensively in the state of Uttar Pradesh (UP), India’s most populous state. With a population of over 180 million, UP also has the highest number of maternal deaths in India (MMR of 440). While rural-urban disparities are well established in India , it becomes clear from the table below that poverty creates wide disparities in access to healthcare in the state of Uttar Pradesh . Type of maternal health service for pregnant women % in lowest wealth quintile % in highest wealth quintile Ante-natal check-up by a doctor 09.1% 60.5% Ante-natal check up by ANM, nurse or LHV 41% 31.8% No ANC received 48.4% 7.2% Three or more Ante-natal check-ups 13.8% 62.3% Received two TT injections 48.2% 92.8% Delivered in a health facility 08.5% 62.5% Delivery assisted by health personnel 12% 73.4% Had a post-natal check-up within 6 weeks 04% 53.9% In 2005, the government announced the National Rural Health Mission (NRHM) with a goal of reducing healthcare inequity between urban and rural India, and providing integrated primary health care to the poor. In response to one of the highest rates of maternal mortality in all of Asia, the Indian government is encouraging more and more rural women to go to hospitals for timely management of complications during childbirth. In an effort to reduce maternal deaths by providing skilled care in hospitals, NRHM gave an impetus to escalate deliveries in institutions such as Primary Health Centres (PHC), Community Health Centres (CHC) and District Hospitals (DH) through offering financial incentives to the women (conditional cash transfer), called the Janani Suraksha Yojana (JSY, meaning mothers’ protection scheme). Pregnant women are informed about the program by the new cadre of workers called the ASHA (Accredited Social Health Activist), whose role includes health education and promotion in the community. Within the JSY rural women in states with high maternal mortality (such as UP) are provided with financial incentives of Rs 1400, and urban women with Rs 1000, provided they deliver their babies in government health centers. The ASHA worker receives an incentive payment and support for transportation costs while accompanying the woman. While large numbers of women are attending government institutions during labor and childbirth, the improvement in infrastructure, health staffing or quality of service delivery is still lagging behind. Pregnant women with any suspected complication are often referred from one health facility to another before reaching a clinic or hospital that is equipped to provide the emergency care they need. Often such referrals are made without any support for emergency transport or information about whether the higher facility actually has the ability to deal with the complication. Both PHCs and CHCs often suffer from severe shortages of trained physicians, low-retention rates of medical staff, inadequate physical infrastructure and facilities, insufficient quantities of medications, lack of accountability to the public and lack of community participation, and an absence of set standards for monitoring quality care etc. The DLHS-3 data indicates that of the PHCs meant to be providing 24-hour services, only 43% had conducted 10 deliveries in the last one month, less than one-third of the CHCs had Ob/Gyn doctors and barely 1% of First Referral Units (FRU) had blood storage facilities, while 6% FRU’s offered Caesarean -sections for complicated deliveries . All this demonstrates a critical gap in the ability of health facilities in rural areas to handle maternal complications or obstetric emergencies effectively towards averting maternal deaths, thus defeating the entire purpose of promoting institutional delivery. While long-term plans to increase the number of women delivering in local hospitals should continue, a major overhaul of the entire Indian healthcare delivery system of sub-centres, primary health centres, and community health centres will not occur overnight.

What we deliver?

In India, roughly one maternal death occurs every five minutes. The maternal mortality ratio (MMR) levels exceed the national ratio in certain geographic areas and are of greatest concern in the northern, central and eastern states. SAHAYOG works intensively on maternal health issues in the state of Uttar Pradesh (U.P.), India’s most populous state. With a population of over 180 million, U.P. also has the highest number of maternal deaths in India (MMR of 440). If complications arise during a home birth, timing proves to be critical in preventing maternal death and disability. There are often three major causes for delay in seeking treatment: delay in seeking care, delay in reaching appropriate care and delay in receiving care at health centres. Through the cultivation of partnerships with mobile phone providers, taxi associations and hospital staff, the project will connect home birth attendants with a quick-response transport system, as well as with a telephone hotline in the district hospital. The project will therefore create synergy between community-based care and institutional care. Research will be conducted across one district of U.P. to determine whether maternal health can be improved through such a synergy and whether a strengthened communication and transport link can help pregnant women access life-saving treatment.

Why is the project unique?

Immediate efforts must be made to address the gaps in the current quality of care available for emergency obstetric care. The leading causes of maternal death in India have been haemorrhage (38%), sepsis (11%), and abortion-related complications (8%) . Timing proves to be critical in preventing maternal death and disability: although post-partum hemorrhage can kill a woman in less than two hours, for most other complications, a woman has between 6 and 12 hours or more to get life-saving emergency care. Similarly, most maternal deaths occur during labor and delivery, or within the first 48 hours thereafter. The ‘three delays’ model (see below) has proved to be a useful tool to identify the points at which delays can occur in the management of obstetric complications, and to design programs to address these delays. The first two “delays” (delay in deciding to seek care and delay in reaching appropriate care) relate directly to the issue of access to care, encompassing factors in the family and the community, including transportation and access to some method of communication. The third “delay” (delay in receiving care at health facilities) relates to factors in the health facility, including quality of care. Unless the three delays are adequately addressed, no program can succeed in averting maternal deaths and disability. There is broad global consensus on three critical maternal-mortality-reducing strategies—skilled attendance at birth, access to emergency obstetric care, and access to referral systems. The proposed project seeks to fill critical gaps in maternal healthcare in UP by directly tackling all three phases of the ‘three delays’ model. Mobile technology is a critical tool needed to ensure an effective referral system. It will directly reduce the first two delays mentioned above and allow for women who are experiencing emergency complications to reach an appropriate health facility that is prepared to treat them in time to ultimately save their life and that of their unborn child’s.


Jashodhara Dasgupta
A-240 Indira Nagar, Lucknow, Uttar Pradesh – 226016, India.

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