Abstract: Over the last two decades major maternity care initiative undertaken by the state has focused on institutional birthing. This has shifted the focus from home births and moved to incentive and fee based institutions/ or services. This necessitates an increasing need to understand how provisioning maternity care is being organised, kind of organisations participating in it and the focus of such services.

This paper maps these initiatives and identifies their trends. While the focus is maternity care, the paper tries to show that with increasing commercialisation and extension of privatised services the immediate maternal health needs of women may be partially addressed, but reaching out to the marginalised groups in the remote areas, urban slums or other spaces remains a far cry. Secondly, even for women, though the new health care provisioning patterns may appear gender neutral, they actually operate with assumptions that are biased against women and impede their access and utilisation.

Keywords: maternal health care, institutional births, restructuring, private sector, commercialisation, re-medicalisation, Maternal Mortality Rate (MMR), Child Survival and Safe Motherhood Programme, Reproductive and Child Health Care (RCH), National Maternity Benefit Scheme, Public Private Partnership (PPPs)

Introduction

Curtailing investment in public sector healthcare has been rationalised in the name of need for efficiency. Outsourcing of different clinical and non-clinical services from the health care institutions and increasing reliance on the private sector and market forces were accepted as the alternatives to public sector expansion. This is the background against which we are trying to assess the drive for institutional births and what it means for pregnant women especially from the marginalised sections. In 2005, Janani Suraksha Yojana was implemented. The government argued that institutionalisation of births will bring down MMR in the country. Research in India over the past seven to eight years shows an increasing trend towards institutional births. The focus of the state has been on trying to meet the cost of institutional births, arrange for referral transports, strengthening primary health care settings and partnering with the private institutions to provide maternity care.

Context

In the past one decade there have been a number of initiatives in the developing countries including India to address MDG 5, improving maternal healthcare and bring down MMR. Both direct and indirect factors operating at the family, community and health facility level contribute to the maternal mortality and morbidity. The state has focused on institutional birthing in public and private sector in order to address Maternal Mortality. Among the set of related causative factors contributing to maternal mortality, Jejeebhoy (2000) says that, “the third set of delays inhibiting safe motherhood occurs at the facility itself”. Institutional birthing has shifted the focus away from Traditional birth attendants (trained or untrained) and home births to skilled birth attendants and hospitals as the core providers of care. Much of organisation of birthing care in institutions (public and private), despite engaging skilled women as care givers, remain insensitive to the needs of birthing women.

It is to be noted that over the 1980s and 1990s growth and expansion of the private corporate health care led to the commercialisation of health care which led to the transition in values and aspirations in public health care institutions (Baru 2005). Impact of this is felt through the restructuring of public health care institutions which ranges from the introduction of market based competitive norms, to poor state resources and shift of subsidies to the private sector and undermining of epidemiological goals (Qadeer & Reddy 2014). It is in this increased interaction between the public and private sector and change in values that, Tibandebage and Mackintosh (2009) observe ‘exertion of power that is leading the crisis of exclusion and impoverishment within many low-income health systems’. Within this environment of commercialisation birthing practices and overall maternal healthcare is increasingly becoming technology oriented with growing sense of alienation and fear among the women (Sadgopal 2009). This necessitates a need to understand how provisions for maternity care is being organised, kind of organisations participating in it and the focus of such services.

The policies and schemes promoting health service provisioning through PPPs, voucher schemes lack gender sensitiveness towards woman patients; rather they operate with biased assumptions impeding women’s access and utilisation. To pursue this play of power, we explore intersection between gender, commercialisation of public health services and place of market in the context of maternity care. Such studies are very few in Indian context. The process of mapping the new schemes becomes imperative to assess their trends and shaping of maternity care services. The paper will draw upon maternity care policy that has initiated restructuring of the maternity care services through diverse provisioning and financing systems that emerged during the period of liberalisation. It also traces the growth of private maternity care facilities during this time. The question is, has the changing provisioning pattern ensured women oriented care? While the focus is maternity care, the paper tries to show that with increasing commercialisation and extension of privatised services, the immediate maternal health needs may be partially addressed but reaching out to the marginalised groups in remote rural areas, in urban slum and in other spaces continues to remain a problem.

Restructuring Maternity care: the Policy Documents

Over the years child survival and family planning has scored over safe maternity care initiatives and women’s health largely remained delinked from the general health services (Qadeer 1998). The provisioning of maternity care gained momentum in the nineties with the launching of Child Survival and Safe Motherhood Programme in 1992. It was underpinned with strong implementation of antenatal care, administration of TT and Iron Folic Acid tablets, institutional delivery, Emergency Obstetric Care and strengthening of PHCs as first referral units. In temperament it largely remained an “extended part of the broad based family planning programme” (Qadeer, 1998). In 1995, Reproductive and Child Health (RCH) programme with an integrated approach was launched. RCH widened the programme ambit but the emphasis remained contraception, AIDS not maternity that had a second place of priority within RCH (GoI 2002).

The tenth five year plan laid emphasis on institutionalisation of child birth but at the same time it reflected the need for a differential strategy in districts with high levels of home and institutional delivery. It discussed the need for providing improved services by training traditional birth attendants in ‘clean delivery’, screening of high risk pregnancy with follow up and referral measures. In this discourse on improving delivery care the point of reference was perinatal and neonatal mortality and maternal care. Women’s health during pregnancy thus gained greater importance. In the eleventh five year plan reiterated similar concerns. It says that to sustain the decline of MMR between 1997 and 2003, skilled birth attendants and emergency obstetric care is essential.

There has been a substantial decline during the seven year period of 1997–2003. However, the pace of decline is insufficient. At the present rate of decline, it will be difficult to achieve the goal of 100 by 2012. This reinforces that rapid expansion of skilled birth attendance and EmOC is needed to further reduce maternal mortality in India. (GoI, 2008: 59)

On one hand this can be interpreted as an initiative to improve the maternity care services, address the critical cases with necessary inputs at the service delivery level and bring down the maternal deaths. On the other hand, it focuses only on complicated pregnancies contributing to MMR and hence, the need for curative interventions which is available only in hospitals and nursing homes. This has a bearing on the way the maternity care services is being designed, organised and provided. The 11th Plan recommended, “Social insurance schemes to facilitate access to reliable maternal care” (GOI, 2008: 88) and suggested to explore services in collaboration with the private sector through schemes like Chiranjeevi Scheme for safe institutional delivery. Couched in the language of inclusion, the private sector is assured securities such as:

Attention will be paid by ASHAs, Anganwadi Workers (AWWs), and TBAs to make arrangements for transport to hospital for EmOC, early detecion, and management of infections. All pregnant women from poor households will be covered by social insurance schemes to facilitate access to reliable maternal care. In this context, all States will be encouraged to experiment with schemes for maternity care (like Chiranjeevi scheme in Gujarat). Positive outcomes will be upscaled and replicated. Every district will have fully equipped Mother and Child Hospital (GOI, 2008: 88).

It prescribes a format for the‘safe deliveries’ through organisation and delivery of maternal health service by trained professionals in institutional spaces such as hospitals and nursing homes, in line with Koblinsky’s (1999) model of care. Through this, the state endeavours to make a dent in women’s health during the phase of pregnancy but in the capacity of a weak state with limited resources. The state seeks help of private sector in meeting the increased demand for institutional births. The focus was more on institutionalisation of childbirth with reimbursement for travel and providers service. It also recognised the continuation of home births but only due to cost factor. Lack of preparedness of the health care institutions in addressing emergency and surgical obstetric cases, unethical practices, and the bad behaviour of the attendants; lack of supportive atmosphere and the sheer difficulty in travelling to the health unit during such conditions was overlooked. Policy recommendation gave minimum focus in addressing the disparities in women’s healthcare across different region and social groups. Further twelfth five year plan projected MMR as ‘a sensitive indicator of the quality of the health care system’ considering increase in institutional births as a mark of development.

Shifts in India’s Maternity Care Service

Institutional Birthing – Stimulating demand by the State

In the arena of maternal health care NRHM has scaled up many of the healthcare initiatives that are multi pronged in nature. It comprises of training ASHAs at the community level to play an active role in promoting institutional delivery. Other areas of concern are, immunisation, strengthening primary healthcare institutions and referral transport system. Addressing manpower needs, arresting out of pocket expenditure and increasing institutional base by inviting private institutions to participate in birthing through voucher schemes, conditional cash transfer programmes and Public Private Partnership (PPP) schemes. The assumption within the policy was that the primary health care was inadequate, not prepared to address essential obstetric care and take up the immediate load of birthing. Second assumption was that small or medium size private nursing homes or hospitals or gynaecologists practicing privately would fill in the demand for increased institutional deliveries. And lastly, protecting out of pocket expenditure incurred for institutional births would encourage institutional deliveries.

This brought about changes in the provisioning and financing of maternity care services particularly in the arena of institutional births. NRHM targeted to achieve 80% of institutional delivery by 2012. In order to bring down maternal mortality several programmes have been introduced starting from National Maternity Benefit Scheme, conditional cash transfer based programme like Janani Suraksha Yojana (JSY), state level Public Private Partnership (PPP) based programme like Chiranjeevi Scheme (CS) in Gujarat, Chiranjeevi Yojana in Assam, Ayushmati Scheme (AS) in West Bengal, MAMTA scheme (MS) in (Delhi), Janani Sahyogi Yojana (JSahY) Madhya Pradesh, Thayi Bhagya (Karnataka). Except National Maternity Benefit Scheme (NMBS), the focus of the other programmes was to shift the base of child birth from home to institutions. Institutional births require preparedness on behalf of the healthcare institutions in order to meet the needs of normal births, caesarean and emergency cases. All these schemes envisage increasing the institutional delivery through strengthening of primary health care centres and usage of private providers providing intra-partum and newborn care services particularly to the BPL families. CS was first operationalised in five backward districts and was later implemented in 21 other districts of Gujarat. In 2008, Extended Chiranjeevi Yojana was launched to encourage private practitioners to establish nursing homes in 40 backward talukas of 16 districts with one time grant of Rs. 5.40 lakh. JSahY in Madhya Pradesh, was initially targeted for BPL families through rural private providers (PPs) but later urban PPs were included. The terms and conditions of this scheme have undergone many changes since its inception. Mamta Scheme is operating in all districts of Delhi. Around 36 nursing homes were empanelled under the state government by the end of 2008. Similarly, AS was started in West Bengal for institutional delivery in 2007 and for deltaic region. In West Bengal, a good volume of caseload in PPP based diagnostic centres located either in the Block Primary Health Centres or Rural hospitals, comprises of maternity cases. There are two reasons; firstly because these health centres do not have diagnostic laboratories of their own, diagonotic centres were established under PPP framework. Secondly, these private diagnostic units could provide cashless service for JSY or Ayushmati cases.

Conditional cash transfer schemes, voucher schemes and state specific PPP schemes has encouraged private sector to participate under different schemes encouraging institutional birthing. Commercialisation of public healthcare provisioning in context of maternal healthcare reflects an increasing role of the private providers (hospitals/nursing homes/diagnostic centres), insurance sector, flat rate compensation and fragmentation of care. As Simon-Kumar correctly points out,

The discourse of gender in the RCH supports the broader rhetoric of the market, and the states discourse on development……. Comments by officials indicate that notions of gender –sensitivity are closely intertwined with values of consumerism. (Simon- Kumar 2006)

This split between provisioning and financing in healthcare services paves the way for vertical approach at the programmatic level to address women’s health risk during pregnancy. This vertical approach has ruptured the organic link between maternal health and maternal death and created an immense space for medicalising maternal health care. This once again helps to hide the link between women’s inequitable social positioning, wage labour, nutritional availability, remoteness, invisibility and her health.

Market for Institutional Delivery

Over the years private allopathy sector has captured a significant proportion of the ambulatory care related to maternal health by both the not-for-profit public and NGO sectors across the country. The share of private ambulatory care is much larger than the overall inpatient care. Studies on private institutional care from nineties and early 2000 have shown that gynaecological/obstetric cases used to make for the major share of caseload (Baru 1999; Roy 2002). In 2009, McKinsey estimated maternity care market share to be of around Rs. 6000 crore with a growth of Rs. 11,000 crore by 2012. It was estimated that out of 400 born per day in Bangalore 10-15% can afford boutique birthing centre (http:// healthcare.financialexpress.com/200903/market01.shtml). This growth in maternity care market is observed since 2005 almost at a time when PPPs for institutional birthing were beginning to emerge. The maternity care market shows that the private corporate sector targeted both the high end and middle – income households with women within the child bearing age group. The private sector has used franchisee and joint venture model for growth and expansion in more than one place. Some of the for- profit sector’s known names in the maternity care segment are Apollo’s Cradle and Fortis Healthcare’s La Femme (New Delhi), Oyster and Pearl Hospital (Pune) and Dr ML Dhawale Memorial Trust (Mumbai).

One of the famous joint ventures of this time is the Life Spring Hospital Pvt. Ltd. by Hindustan Latex Ltd. (HLL), along with Acumen Fund, (non-profit venture philanthropy fund) started this hospital catering to maternal and child healthcare for lower middle class in this country. There are now 12 hospitals in the low income areas of Hyderabad with bed capacity of 20-25. Financial sustainability in private sector is a critical factor that determines the operation of such institutions. In the course of its operation, Life Spring had to close some hospitals and relocate the others due to required lack of patient volume (CHMI 2012). Recently it stopped ANC and PNC field visits by its staff nurses for the cost factor and has become a largely midwives led hospital. Another similar venture started by HLL in 2007 is Merrygold Health Network (MGHN) in Uttar Pradesh. It has adapted the franchisee business model in 36 districts of UP providing ANC, birthing, PNC, child care and family planning services. Since the target group is very different compared to the purely corporate health care providers, MGHN provides services at rates much lower than the market price. Low cost private model prefers to provide standardised care and tend to work in better off and urban spaces. Interestingly, the low end private providers have either used government funds or expressed their need for government support for their functioning and continuation. Life Spring uses the government’s 108 ambulance service for their referral transports. Both Life Spring and MGHN have expressed their desire to provide free care through PPP with the state government (Misra & Misra 2014). Over the past one decade there have been few other low cost private sector maternal health care programmes like Janani in Bihar and Jharkhand, DiMPA1 and Saathiya network in Uttar Pradesh and Saadhan network in Uttarakhand.

All of this adds up to a picture of segmented market for maternity care targeting women with differential income inclusive of those willing to pay or with insurance coverage. Market segregates women into two broad categories based on the patriarchal assumptions. First those poor women who will access services based on exemptions or concessions, and secondly those for whom fees will not act as an impediment irrespective of the cost. This segmented market is projected as providing multiple options for maternal health care to women with ‘quality services’, the ability to ‘choose’ …. and ‘pleasing service interactions’ as gender sensitive markets (Simon-Kumar 2006).

Implications for Maternal Care and Health

Previous sections indicate that with commercialisation of the public and private sector, maternal health care has emerged more as a packaged set of services than an integrated or inclusive service. This maternal healthcare approach has differential impact on women across different social and class background. Theoretically health sector reform has co- opted the language of women’s health movement equity, universal access with better quality of care, integrated and comprehensive services but in real practice expansion and creation of markets in healthcare has distorted the same. The implementation of PPP schemes and JSY throw multiple challenges in terms of equity, access, continuation of services, quality of care and ethical practices.

Location of Private Providers (PP)

Location of empanelled PPs under the PPP schemes is vital as they target BPL / underprivileged population in remote and inaccessible areas and also influence the Out of Pocket Expenditure (OPE). Private health care providers are commonly located in the economically better off districts and in the urban centres. Private providers empanelled under Chiranjeevi Scheme in Surat lived in better off places where women and their families found access difficult because of the cultural gap (Acharya & Mcnamee 2009). Anaesthetists were available on call. They being urban based expected to be remunerated and expressed their reluctance in attending to BPL cases. JSY experience in Madhya Pradesh shows that due to very few rural PPs and their inability to meet the terms and conditions, urban based PPs were selected. In six districts 90% of the PPs were urban based. Thus, the PPP mode could little supplement the public provisioning in rural areas (NIHFW 2008).

Free Care, Out of Pocket Expenditure (OPE) & Commercial Interest

Even though under these schemes the beneficiary is eligible for free treatment and birthing but the evidence is otherwise. It has been reported that women across the empanelled private and public sector incurred OPE. In PPP as well as in conditional cash transfer scheme the women’s family incurred OPE for institutional deliveries and borrow as well. Under CS in cases women who did not have BPL certificate on arrival incurred additional payments for medicines, transport, and advance payment. Although in some cases money was returned back but all this added to and increased OPE (Jega 2007). Even when the care is subsidised in the private sector by the public sector, patients have to incur out-of-pocket expenditure. Empanelled private providers under the PPP tried to cut down their cost through contractual appointment or hour basis terms with anaesthetists or Obstetrician which resulted in inadequate personnel. This forced complicated obstetric cases to be referred to either the public sector or the urban private providers from rural private providers. It was also reported that CS did not help in bringing down the cost in the private sector even after five years of operation (Mohanan et. al., 2014). For antenatal checkups, three-fourth of the users under Mamta Scheme had to bear charges for diagnostics and medicines. Post natal check up services were utilised by more than 50 % of the beneficiaries, but in case of more than one check up the empanelled providers levied charges on them (NIHFW 2010). Similarly, under the Janani Sahyogi Yojana in Madhya Pradesh around 45% of the PPs charged money for services and more in urban based districts of Indore, Jabalpur and Chhindwada (NIHFW 2008).

In case of institutional birthing under JSY in West Bengal and Assam, cash assistance was not enough and the families had to bear OPE. The beneficiaries had incurred out of pocket expenditure, almost 52% more (Uttekar et.al 2007 and 2007a). As a result, the poorest of the poor can benefit little from JSY. Borrowing for institutional birthings (normal and cesarean) in public and private sector was noted among one-third of the families even after JSY was implemented (Modugu, et. al. 2012). Irrespective of this provision of free care, women’s family had to bear OPE which resulted in borrowing or increased financial burden.

With increasing restructuring of provisioning systems, commercial interests seem to threaten or undermine the ethical practices. Functioning of PPs empanelled under PPPs reflect their commercial interest which fails to act in favour of those poor pregnant women it targets. It is observed that during renewals empanelled PPs expressed to discontinue till they find it remunerative enough or user charges / incentives are not revised (NIHFW, 2008; 2010). Apart from this, in private hospitals or nursing homes overall rate of C- section is higher and increased usage of oxytocin and minor surgeries like episiotomies is also noted. Such practices are not always shaped by clinical need but are rather framed by market interactions. In states with demographic transition and large scale unregulated growth of private sector like Tamil Nadu, Kerala, Andhra Pradesh and Goa the rate of C-section is very high (Ghosh 2010). Post C- section, cases of surgical site infection has been reported, adding to the risk of postpartum maternal infection. These institutional unethical practices add risk to the normal births.

Access and Quality

Prior to 2013 pregnant women below the age of 19 and with more than two children were barred from entitlements listed under JSY. However, this norm has not been revoked for the state sponsored schemes for institutional birthing. Around 47% of girls are married before the age of 18 years (GOI 2009). This narrow targeted focus leaves out large section of adolescent girls married below the age of 19 and multiparous women who are more prone to maternal and perinatal outcomes. This norm particularly puts women from socially and economically backward groups (SC, ST, OBC) at a disadvantage. Attempts to provide universal access to maternal healthcare still remains exclusionary under such targets.

The experience of hospitalisation under different PPP schemes does not directly translate into safe delivery for the women as services are not always adequate (NIHFW 2010, 2009, 2008; Barnes 2007 as in Sadgopal 2009; Acharya & McNamee 2009; Jega, 2007). Evaluation of JSY in different states also point towards shortages in infrastructure, manpower, drugs and equipments. A study of JSY in Orissa pointed out there was shortage of operation tables, equipments and instruments to meet the increased load and cleanliness was not maintained in the labour room (Nandan et.al., 2008). Lack of preparedness in basic services in hospitals and health centres then, contributes to negative outcome in terms of mortality and morbidity.

Even though most of the maternal deaths occur at early post partum period, postnatal care components have not been strengthened. Within the existing Postnatal Care, emphasis is on new born care. Outcome of these institutional births has reaffirmed the need for quality intra-partum and post partum services that contribute to maternal morbidity and mortality. Study of Janani Suraksha Yojana in a tertiary hospital of Jabalpur district from, Madhya Pradesh showed that the overall MMR increased among the rural women after the implementation of JSY (Gupta et.al., 2012). It also showed that anaemia was the most common cause of morbidity and those who came for institutional births showed an increase in cases of eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria (Gupta et.al. 2012). In fact in-depth study of maternal deaths in Barwani (2010), Madhya Pradesh showed lack of preparedness for post- partum care in the health facilities. Sometimes women were forced to stay for 48 hours under very difficult and unhygienic conditions in order to become eligible for the cash incentives (Sri et. al. 2012, Karpagam, 2014 as described in JEEVA workshop).

Reform in Public Provisioning

Post NRHM there has been initiatives to revive the government primary health care system. In rural and remote areas women still depend upon these institutions where services are most importantly- free of charges. Evaluation of NRHM in the seven states (Uttar Pradesh, Madhya Pradesh, Jharkhand, Tamil Nadu, Orissa, Assam and Jammu& Kashmir) reveals that under the PPP initiative of JSY involvement of NGOs was almost negligible (GoI 2011). Large section of the women in the periphery (rural areas, tribal areas) depends on the primary health care system for ANC and birthing. Assessment of 74 CHCs in seven states showed that only 28% had facilities for attending to complicated pregnancy cases. Among the 10 CHCs selected for evaluation in Jharkhand none had the facility for EmOC and other surgical intervention if required. Around 54% of the CHCs in the study had laboratory facilities except in Uttar Pradesh and Jammu where all the CHCs had lab test arrangements (GoI 2011). Inspite of these shortcomings, experiences of JSY show that it has somewhat popularised institutional birthing in low performing states. In states like Uttar Pradesh, Bihar, Assam, Orissa institutional birthing have increased. Review of JSY shows an increase in ANC registration, institutional births and PNC utilising primary health care institutions.

This has lead to overloading and pressure on obstetric and paediatric wards of the district hospitals. Institutional births require preparedness at various levels like bed strength, manpower (nurse, cleaning staff), materials and medicines etc. Interestingly in majority of the district hospitals cleaning and food service has been outsourced (Roy 2007). In the context of post partum maternal and neonatal morbidity cleanliness and sanitary conditions of wards was poor. Even though there is increased access to the district hospitals for birthing driven through incentives, the above mentioned lacunae compel poor and marginalised women to be part of poor standards of care which violates their right to health and is discriminatory (Roy B, field observations from West Bengal).

Conclusion:

This paper brings out the fact that the focus on institutional births coincided with restructuring of public sector health delivery, expansion of private healthcare (through hospitals and diagnostic centres), and penetration of health insurance. PPP measures, voucher schemes conditional cash transfer and insurance based schemes are seen as innovative schemes within the literature on maternal health care but they also speak about the increasing market power over women’s health. It is in the development of health care market women become the agency. The segmented nature of private care for institutional births shows that women are not considered as one socialy and economicaly homogenous category. The private healthcare market focuses on the class background of women as agency to expand as providers. Specialised low end private maternal care providers have contributed to the expansion of self pay market2. Nonetheless, this private sector targeting the lower end still fails to reach out to the women who are poor, belong to the SC / ST / OBC and who work hard to meet their ends. Empanelment of the private sector through PPP and JSY was the next step to reach out to the marginalised women with no paying capacity. Through PPPs there is an effort to make certain part of the segmented marketised care inclusive and affordable for the poor and marginalised section of women. Thus the health care services are no more universal or equitable but, stratified based on the social and economic background of the women. This goes to show that organisational and financial reforms related to birthing redefines the relationship between women, services, providers and the state’s bias in favour of the market.

In a scenario of not enough studies, there is a need for more research as the state provisioning in maternal health care becomes more marketised and medicalised. Some of the questions that need to be addressed are: In this split between provisioning and financing how far women with marginal social and economic status can access maternal health care facilities? Can institutional births help to reduce maternal mortality ratio? To what extent health care institutions can address complications? Who benefits from institutional births and medicalisation of birthing?

As observed in practice, it is important to address many lacunae and unethical practices at the institutional level (public and private). At the policy level it is critical to prevent commercialisation of maternal health care as ‘marketplace is not just a step backwards toward (re)medicalisation, but a dangerously reductive view of women’s health needs’ (Lippman 1999). We are still in a situation when maternal mortality rate is high3 and the decline is far from satisfactory among the states with high concentration of scheduled castes, scheduled tribes. It is critical to reorganize that, commercially and biomedically oriented institutional care alienates further women of marginalised groups from healthcare services. There is a need for the state to recognise and strengthen the pluralistic maternal health care services i.e socially and culturally rooted. And there is also need to increase investment in sector which influences women’s health such as in nutrition programmes, sanitation, availability of clean drinking water, general health care services in primary health care settings, recognising traditional birth attendants and their skills in attending home births. These are the challenges for the state in addressing issues of maternal healthcare and thus, women’s health.

NOTES

1 Depot-Medroxyprogestrone Acetate

2 Self pay markets are those where the consumer pays for the service from their own pocket and is not reimbursed.

3 From 1990, MMR worldwide declined by 45% and of the two countries that contribute for one third of all global maternal deaths India accounted for 17% of the maternal deaths (WHO, 2013). Regional distribution of maternal deaths across the states still shows high unevenness from 480 in Assam to 95 in Kerala. The states where MMR is above 300 are Rajasthan, Uttar Pradesh, Madhya Pradesh / Chattisgarh, Orissa, Bihar / Jharkhand and Assam.

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Earlier version of this paper titled ‘Public Private Partnership Models for Safe Motherhood: Critical Issues’ was presented at International Workshop on Health Risks, Poverty & Vulnerability in South Asia, University of Hyderabad, 11-12 March 2011.

Contributor:

BIJOYA ROY. Is a public health researcher by training. She holds a Ph.D. from Centre of Social medicine and Community Health, Jawaharlal Nehru University, New Delhi and works in Centre for Women’s Development Studies, New Delhi. Her research work revolves around health care service delivery models, commercialisation and medicalisation of health care using mixed research method and maternal health care.