By the time you finish reading this, another woman in India would have died from complications related to pregnancy or childbirth. India averages one maternal death every 12 minutes – the second highest number of maternal deaths worldwide. For an estimated 45,000 Indian women every year, getting pregnant turns out to be a death sentence.
It doesn’t have to be that way. We know the interventions that save lives: antenatal checkups for expectant mothers, delivery with a skilled attendant, postpartum care, access to safe abortion and contraception. Yes, contraception.
It is estimated that maternal mortality could be reduced by a third just through the healthy timing and spacing of births. That means delaying first pregnancy until a woman is at least 18 years old (20 is even better) and waiting two to three years after childbirth before trying for another baby. It is essential to women’s health that they be able to control whether and when they get pregnant, and that means they need access to contraception.
EngenderHealth has worked for almost 20 years to improve contraceptive and maternal health services in India. The non-profit is currently leading projects in Rajasthan, Gujarat and Bihar to reduce maternal mortality and morbidity through increased access to contraception, particularly intrauterine devices (IUDs) and permanent methods. As with all of its programmes, the focus is on high-quality, rights-based, client-centred healthcare that puts women’s needs, values and preferences first.
So how can the national family planning programme be strengthened to ensure that as many women as possible have access to life-saving contraception? These are what are seen as the chief priorities:
Invest in provider training
Women in India want what women everywhere want: quality care from highly-skilled professionals who treat them with respect and dignity. This has to be the core foundation of any family planning programme, and is essential if women are to feel comfortable seeking out the services they need and deserve.
That’s why the training curriculum for providers needs to do more than just cover clinical issues. It needs to offer a thorough grounding in the principles of rights-based healthcare, including informed choice, voluntary decision making, client safety and service quality. A strong programme of structured on-the-job training, clinical monitoring and coaching and follow-up support could go a long way towards improving the quality of family planning services in public health facilities.
Integrate family planning with maternal and child health services
The ideal time to reach women with contraceptive services is when they are already in contact with the healthcare system: during antenatal counselling, in the postpartum period, or when they bring their children in for immunisations.
The immediate postpartum period is particularly important, since most postpartum women want to delay a subsequent pregnancy and need an effective method. The steep rise in the percentage of Indian women who give birth in hospital settings means that the majority of postpartum women are already at a facility. They should be offered counselling and the full range of contraceptive options, including the postpartum IUD, as an integral component of their care.
Pay attention to the special needs of young people
Young women in India urgently need access to contraception, yet face enormous obstacles to obtaining it. If they’re married, they’re usually under intense pressure from their families and communities to prove their fertility and bear sons. If they’re unmarried, they’re under equally intense pressure not to engage in sexual relations at all. Because young people in India often receive no sexual or reproductive health education, innovative strategies need to be designed to reach them with critical information about their health and rights.
One of the biggest obstacles young women face is the personal beliefs and biases of service providers about what methods of contraception, if any, are appropriate. Poorly trained providers routinely violate young women’s reproductive rights by refusing to prescribe contraception. Service providers need to be specifically trained on youth-friendly services, with a focus on rights, non-judgmental and respectful communication and the importance of privacy and confidentiality.
Expand the method mix
The national family planning programme in India has traditionally emphasised short-term methods (pills and condoms) and permanent methods (sterilisation). But the basket of choice really needs to be much broader than this for women to be able to find a method that suits them personally, fits in with their reproductive plans and enables them to space or limit births as they wish.
Long acting reversible contraceptives (LARCs) are especially useful for birth spacing, since these provide protection for years at a time. IUDs are currently the only LARCs included in the public health system. The addition of implants – thin plastic rods which are inserted in the upper arm and last for three or five years – should be considered for the future.
The government’s recent decision to include injectables is also a step in the right direction. Injectables, which last for three months at a time, are by far the most popular contraceptive method in sub-Saharan Africa. Women in those countries have used injectables for decades, and find them much more convenient than taking a pill every day. Injectables also have the potential to be self-administered, which would bring Indian women a whole new level of privacy and convenience.
With any method it is critical to ensure that a robust supply chain is in place. A woman can’t find and stick with a method she likes if she can’t count on it being continuously accessible.
Reach women where they are
Women shouldn’t have to go to a health facility just for routine contraceptives or information. A reliable supply of products and access to high quality counseling should be available in every village and urban district. India’s thousands of Accredited Social Health Activists (ASHAs) are already positioned to provide these vital services. Similar programmes in Asia, Africa and Latin America have proven that community health workers can safely and effectively provide a full range of short-term contraceptive methods, including injectables. With quality training, a solid supply chain to back them up and institutional support behind them, the ASHAs can be effective frontline providers of family planning services.
India’s maternal death toll is a tragedy, but it’s a tragedy we can end. The evidence is abundant and clear: contraception saves lives. Let’s make sure every woman has access to it.
Ulla Müller is the President and CEO of EngenderHealth. Shumon Sengupta is the Asia Regional Representative for EngenderHealth.