Melissa Upreti with the Center for Reproductive RightsNEW DELHI (WOMENSENEWS)–With India showing little signs of budging from its global laggard position on maternal mortality, health advocates are promoting legal remedies to push the country toward national and U.N. targets on this score.

"Laws provide a strong basis to hold the government accountable for maternal deaths," said Melissa Upreti, a senior legal advisor to the New York-based Center for Reproductive Rights, which in 2004 launched a global initiative to promote strategic litigation to achieve women’s reproductive rights worldwide.

The Human Rights Law Network, a New Delhi-based nongovernmental group, offers an example of how legal rights advocacy can help.

The group has filed several public interest lawsuits seeking better implementation of the government’s National Rural Health Mission, a seven year initiative with a 2012 end date to reduce maternal mortality, improve service delivery and increase equity and access to services, especially in states with the lowest health indicators.

One such lawsuit exposed the failure of Madhya Pradesh, the state with the country’s third-highest rate of maternal mortality (379 deaths per 100,000 live births), to implement policies designed to improve prenatal and postnatal care. Since the suit was filed in July 2008, a blood bank was set up at Bhind Hospital in the state, fulfilling one of the law’s service guarantees.

Meeting Targets Unlikely

India’s own population policy aims to reduce the country’s maternal mortality to 100 deaths per 100,000 live births by 2010. Currently there are more than 300 maternal deaths for every 100,000 live births.

Under one of its Millennium Development Goals–a set of U.N. targets for eradicating world poverty–the government pledged to lower maternal deaths to 200 per 100,00 live births by 2007 and to 109 by 2015.

Anand Grover, an Indian lawyer and U.N. special rapporteur on the right to health, says current targets are out of line with reality. "At the current rate it would not be possible to achieve the target of one-third reduction in maternal mortality ratio by 2015," said Grover. "These are preventable deaths. There is no justification for maternal mortality. The biggest cause is discrimination and the lack of equality that prevents women from accessing information and services."

The latest National Family Health Survey concluded that 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 will continue to suffer.

Upreti, at the Center for Reproductive Rights, recommends that health advocates use a combination of constitutional guarantees and international laws to press for the implementation of Indian women’s rights to survive pregnancy and childbirth.

In India, women are supposed to have the right to free maternity care. However, in reality health providers ask pregnant women to pay money for services. In the state of Uttar Pradesh, the inability to pay has been identified as a leading cause of maternal death by one nongovernmental group working there.

Countrywide Campaigns

Groups across the country have begun campaigning for state accountability to ensure equal rights for women. For example, Uttar Pradesh, India’s most populous state, has the highest maternal mortality rate: 440 deaths per 100,000 live births. Public hearings have been organized in the state to bring attention to the gaps in delivery of entitlements under the National Rural Health Mission. This has been documented to feed into a larger legal campaign to fight for maternal rights across the country.

It is hoped that this effort will build on the success achieved by "Complete Citizen, Total Rights," an earlier campaign initiated in Uttar Pradesh to demand accountability on the basis of constitutional obligations to protect, promote and fulfill women’s rights. This campaign was initiated by Healthwatch Forum, a network of nongovernmental organizations.

In addition, the "Deliver Now" campaign, begun in April 2008 by the Partnership for Maternal, Newborn and Child Health, a global health partnership launched by the World Health Organization, and the New Delhi-based White Ribbon Alliance of India, has stepped up efforts to raise awareness about women’s rights to survive pregnancy. It also aims to help women demand their rights, such as receiving iron tablets, anti-tetanus shots and other routine measures during pregnancy and after childbirth.

In India, more women die due to maternity-related causes than anywhere in the world. Roughly one maternal death occurs every five minutes, adding up to one of the world’s highest rates of maternal mortality of more than 300 maternal deaths for every 100,000 live births.

In Sri Lanka, the corresponding figure is 56, in China it is 45, in Namibia it’s 210 and in Egypt, 130.

Less than 50 percent of Indian women give birth with the assistance of a skilled attendant and only 40 percent of deliveries occur in an institutional setting.

Reproductive Rights Training

In 2006, the Center for Reproductive Rights organized the first training on reproductive rights for lawyers in India, in collaboration with the Human Rights Law Network. At this meeting, the potential for developing constitutional litigation to address maternal mortality through the use of international norms and comparative law was realized. Since then, the organization has trained many lawyers in Indian states with a high maternal mortality rate.

In August, Upreti and Grover were among speakers at a public health meeting here organized by Healthwatch Forum with the support of the Center for Reproductive Rights.

The meeting was part of a 15-year-review process for the International Conference on Population and Development held in Cairo in 1994, which helped foster an integration of population issues in development policymaking.

It pushed for a rights-based approach in health through the adoption of reproductive rights. In June 2009, on the 15th anniversary of the watershed meeting, the U.N. Human Rights Council adopted a resolution recognizing preventable maternal mortality as an issue of the human rights of women and girls.

The maternal mortality rate in India was even higher around the time of the 1994 Cairo meeting. The National Family Health Survey of 1992 to 93 provided a national-level estimate of 437 maternal deaths per 100,000 births.

Three Types of Delay

Researchers at the August meeting blamed the country’s dismal maternal mortality statistics on three types of delay: the delay by women in deciding to seek care, reach the appropriate health facility and receiving quality care once inside an institution.

Speakers cited research showing that many families are too intimidated to ask or question the services they received because of their socioeconomic background.

Thus, even if pregnancies are registered under the government rules, it does not guarantee improved prenatal care or access to nutritional support offered under government schemes.

Most deaths occur among poor women with little or no education who belong to the traditionally disadvantaged groups, such as those who have been scheduled for government assistance because of their known economic, social and educational disadvantages.

Adolescents forced into early marriage also add to the sobering statistic.

Access to maternal health varies by state. Low-income and rural women have the least access to heath and quality care.

One nongovernmental group working for women’s health rights validates this unfortunate fact with the story of Gulabo, a 23-year-old woman of a marginalized community in Uttar Pradesh who was denied lifesaving care because she had neither the money nor confidence to demand her rights. She gave birth outside the gates of the local hospital.

The newborn died within an hour and Gulabo died later that night.

Swapna Majumdar is a journalist based in New Delhi and writes on development, gender and politics.