A/HRC/14/20/Add.2
made indispensable contributions to monitoring and accountability in relation to the right to
health. However, with honourable exceptions, these arrangements are not robust. For
example, community processes within the National Rural Health Mission are patchy.
According to one independent report of 2008, community-based monitoring in Rajasthan
has started in some pilot districts, “but the result is not very encouraging as there is minimal
participation from health officials, and they view it threateningly as if a public trial”.37
64.
Moreover, even if they were working well, India’s existing monitoring,
accountability and redress mechanisms are dwarfed by the enormity and complexity of the
country’s public and private health sector. Neither the basic instruments (e.g. indicators for
EmOC), nor the basic machinery (e.g. maternal death reviews) are firmly established. In
short, India’s current monitoring, accountability and redress mechanisms in relation to the
public and private health sector are not fit for purpose.
65.
A country must have a range of mechanisms for monitoring, accountability and
redress in relation to maternal mortality. The following paragraphs provide a sample of the
relevant issues and some recommendations.
1.
Counting maternal deaths
66.
Numerous countries do not accurately measure maternal mortality,38 and India is no
exception. Although the Registration of Births and Deaths Act (1969) makes it mandatory
to record all births and deaths, it is well known that this civil registration system is not
working properly. There is evidence that the majority of maternal deaths in India are not
recorded.
67.
The authorities do not have a sufficiently robust method of estimating maternal
mortality on a routine basis.39 The Sample Registration System, for example, produces
annual crude birth and death rates, and the infant mortality rate, but it does not generate
yearly rates for maternal deaths. The System has other drawbacks and reportedly provides
inaccurate estimates for maternal deaths.40 In 1999, three different studies estimated India’s
maternal mortality rate at 540, 466 and 396 per 100,000 live births, the first and second
estimates being based on the same data.41 Because of uncertainties about data, a major
global study recently published in The Lancet estimated India’s maternal mortality in 2005
to be between 300 and 600 per 100,000 births, a very large uncertainty bound.42
68.
A study on maternal mortality in rural Rajasthan found that only 45 per cent of
maternal deaths were registered by the official system of births and deaths.43 While visiting
Rajasthan, the Special Rapporteur was informed by one official that, in his judgement, even
fewer than 45 per cent of maternal deaths were registered. A study on a district in Gujurat
suggests 82 per cent underreporting of maternal deaths.44
37
38
39
40
41
42
43
44
16
India, “2nd Common Review Mission: Rajasthan”, p. 21.
Hill and others, “Estimates of maternal mortality worldwide between 1990 and 2005: an assessment
of available data”, Lancet, vol. 370, No. 9595 (13 October 2007), p. 1311.
Vora and others, “Maternal health situation in India”, p. 22.
Ibid., p. 7.
T. Puwar, P. Raman and D. Mavalankar, “Situational analysis of reporting and recording of maternal
deaths in Gandhinagar district, Gujarat State”, Working Paper No. 2009-06-01 (Ahmedabad, IIMA,
2009), p. 7.
Hill and others, “Estimates of maternal mortality”, p. 1315.
Iyengar and others, “Pregnancy-related deaths in rural Rajasthan, India: exploring causes, context,
and care-seeking through verbal autopsy”, Journal of Health and Popular Nutrition, vol. 27, No. 2
(April 2009), p. 295.
Puwar, Raman and Mavalankar, “Situational analysis”, p. 17.
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