WHAT IS PUBLIC HEALTH

India is considered as a land of origin of surgery by great Sushruta and the origins of
Ayurveda have been traced to around 6,000 BCE which is very ancient. There have
been various developments in the health sector in the post independence era. The
health indicators are improving post independence. But still India is not capable of
achieving some health indicators as compared to developed country. It seems that
spending 1.28 % of GDP on health care system is no going to help only. (1) Public
health is a scientific and rigorous approach for improvisation of life.

A definition of public health in the Oxford Textbook of Public Health presents its multiple
dimensions: ‘‘Public health is the art and science of preventing disease, prolonging life,
and promoting health through the organized efforts of society. “The goal of public health
is the biological, physical, social, and mental well-being of all members of society as
health is not only physical absence of disease or deformity (2) Thus, public health must
address the challenge of confronting health problems and political, social, and economic
factors affecting health, not only at the community, state, and national levels, but at the
global level as well.

For instance if there is a pregnant women facing post partum hemorrhage(PPH),

Clinicians main focus is the immediate problem, stopping the hemorrhage, the
individual approach. But Public health approach would be holistic and figuring out how
and why this happen, so that actions can be taken to prevent it happening again and
what should be the emergency preparedness for that particular problem. For example
why did the PPH happen? Why PPH resulted in death of Patient? Is it because of
unpredictable nature of healthcare cause or poor knowledge of complications of
pregnancy, bad attitude towards health, what was the community aspect and attitudes
towards it? does she has a social support network who will help her to recovery or
happening again, what are the government policy and program to support females or
other legislations. Does it was reported, does she was in hospital on time, if not then
why? Why delay? Is it inaccessible place or unavailability of transport to reach? Could
she not afford it? Does she is poor? Does she could not have access to education?
Then why? Why family could not afford the price? So health is determined by a
complex interaction between different factors and determinants of health. This includes
individual characteristics, lifestyle and behaviors and also the physical, social and
economic environment factors (2).

HEALTH INEQUALITIES

Health inequalities are unfair (unjust) and avoidable differences in health across the
population, and between different groups within society while equity is more related to
moral and principle. Healths inequalities arise because of the conditions in which we are
born, grow, live, work and age. These conditions influence our opportunities for good
health, and how we think, feel and act, and this shapes our mental health, physical
health and wellbeing.

Health inequality is a descriptive term that need not imply moral judgment. Consider
individual A who dies at age 40 during a sky diving accident and His identical twin, B,
who does not enjoy this hobby, lives to age 80. In this case, the unequal life spans of A
and B, the unequal life expectancies of entertaining sky divers and non-divers, reflects a
personal choice that would not necessarily evoke moral concern. Sometimes health
inequalities are absolutely inequitable such as pure chance (random genetic mutation)
and life stage differences. (3)

HEALTH INEQUALITIES IN INDIA

According to WHO reports, India is gradually improvising its health care system over the
decade. The life expectancy has crossed 69.42 years. The infant mortality rate has
declined from 74 per 1,000 live births in 1994 to 37 per 1,000 live births in 2015. On the
other hand with growing economy ,gap between poor and rich is growing day by day
which is ultimately resulting in numerous health inequalities in Reproductive-Maternal-
Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-
Communicable Diseases affecting health care.(4)

Maternal mortality is a major challenge to the global public health system. India
contributes about 27 million births per year in the world and accounts 20% of global
maternal deaths (5). India contribute one fifth of global burden of absolute maternal
deaths despite economic growth and impressive advancement in the fields of science,
agriculture, and medicine and information technology. The maternal mortality ratio in
India was 16 times higher than that of Russia, 10 times that of China and 4 times higher
than that of Brazil in 2005(6). BBC World Service wrote the following about Maternal
mortality in India: "Imagine 400 planes filled with women and girls and crashing into the
sea with no survivors, that is the volume of women and girls dying in India due to
pregnancy related causes"().This graphic description is enough to shake one's senses
but is unfortunately an extremely sad reality faced by India.

SIGNIFICANCE AND CONSEQUENCES OF MATERNAL DEATH

The death of a woman in pregnancy and childbirth is globally considered an individual
tragedy and a human rights violation. Maternal mortality inequities in death that occur to
marginalized, poor, and vulnerable women in low and middle income countries, there is
no doubt that maternal death is a horrific injustice

There are consensus that the loss of a mother is not just a grievous single event to the
family, but that has large and negative effects on the surviving children, spouse, families
and communities.For instance, an Ethiopia longitudinal study found that babies who
experienced the loss of a mother within their first 30 days had 46 times higher risk of
dying compared to those whose mothers survived. Poor health care is big issue for
orphaned child with lower rates of immunization and ill child seeking medical health.
Fathers are rarely assumed child care as their responsibilities, home care, cooking.
Husbands are not only bereft but ill prepared to handle the role expansion required after
losing a wife. With loss of wife, not only additional income is lost but also huge dept is
required for hospital bills, funeral costs. Some families need to to sell assets resulting in
more borrowing, more debt, surviving children get suffered and if the child is girl then
she face worse-compromising everything on each stage of life(7)(8).

A similar result was found in a study from rural Tanzania, indicating that children
orphaned by an early maternal death had a 48% probability of dying before their first
birthday compared to 6% for those whose mothers survived. (11)  

From the qualitative study of impact of maternal mortality on children and families
justifies that Newborns and children whose mothers died from maternal causes face
nutrition deficits, and are less likely to access needed health care than children with
living mothers. Older children drop out of school to care for younger siblings and
contribute to household and farm labor which may be beyond their capacity and age,
and often choose migration in search of better opportunities (12)

Women is truly the center of the home, production, reproduction, social relations,
socialization of children, guardians of morality, education and health; if she dies, all
functions related to her role suffer.  An average of 32.0% reduction of annual income
and 24.9% reduction of annual expenditure were observed in households with a
maternal death. The increase in debts was 3.2 times as high as that in households
without maternal death. According to cohort study of Economic Impact of Maternal
Death on Households in Rural China gave findings that households with maternal death
had a significant relative reduction of income compared to those households that
experienced childbirth with no adverse event(13)
MATERNAL MORTALITY ENEQUALITIES IN INDIA
Maternal mortality is the maternal death of a woman during pregnancy or after
pregnancy, including post-abortion or post-birth periods. It is globally known that India is
stratified in gender, caste, religion, education, wealth and urban –rural dimension.
Socioeconomic, demographic and cultural factors are the major determinants of MMR in
India. Social factors which influence maternal mortality in India are income inequality,
level of access to prenatal care and care in the postpartum period; level of woman's
education; the position of the mother's community in the regional rural-urban divide; the
mother's access to nutrition during pregnancy; the degree of local sanitation; and the
caste position of the mother (14)

ECONOMIC INEQUALITY:
Maternal mortality ratio India 2015-2017 by state

According to recent estimates, nearly 28 percent of the Indian population lived below
the poverty line with large inter-state variations (15).There is strong evidence to suggest
that income inequality or disparity between the different socioeconomic classes is
associated with worse health outcomes.(16)Poverty is largely concentrated in the
central and eastern states if India, namely, Bihar, Orissa, Chhattisgad, Jharkhand,
Madhya-Pradesh, Uttarpradesh where poverty is higher than national average and
these states together accounts for 55% of total poor population in India. The use of
maternal care services is relatively low in these areas according to NHM state survey of
India.(16)(17) On the contrary the western and southern the states Gujarat,
Maharashtra, Kerala, Tamilnadu, Andhra, Karnataka are economically and
geographically advanced than northern and central part of India. Kerala has only 42
MMR which is less than half maternal deaths in India in 2015-2016(18) (19). Studies
have documented a negative association between the use of maternal care and
maternal mortality ratio.(20) Ninety-four percent (94%) of all maternal deaths occur in
low and lower middle-income countries.(21)(22) In poorer states, urban women access
healthcare much more often than rural women (24). Study clearly stated that the use of
post natal care (PNC) and skilled birth attendance (SBA) remains disproportionately
lower among poor mothers in India irrespective of area of residence and province.()

GEOGRAPHICAL LOCATION -

The most vulnerable and excluded group from healthcare are those in remote hamlets,
tribal villages as well as most of rural areas. There is considerable the rural-urban
disparities in the use of SBA and PNC. In poorer states, urban women access
healthcare much more often than rural women (24).

Assam has the highest MMR of all India’s states, almost double the national average,
with around 229 deaths per 100 000 live births. (26) According to Tulic Goswami
Mahanta –associate professor of community medicine at Assam medical college, three
quarters of these deaths are in tea plantation. The highest rates of maternal mortality
are among tea plantation workers. It is very true that tea garden workers often lack
access to basic service including schools, healthcare, latrines, safe drinking water and
food stores despite 1951 plantation labor act(drawback-only applicable to permanent
workers). Their dependence on the industry leaves them vulnerable to exploitation and
resulting in limitations to development deteriorating their health. MMR is more in tea
gardens in northern districts. The problems faced by these workers are difficulty to
access to these services; hospitals are far away from home resulting in home deliveries,
postpartum hemorrhage (leading cause of MMR through the world). Furthermore, many
tea garden hospitals on site have poor services; lack of doctors, adequate trained staff,
and insufficient birthing facilities makes negative impact on the families who visits the
hospitals for services. (27)

EDUCATION:

Mother’s education is one of the most important factors contributing to the inequality in
the utilization of full ANC. The use of ANC facilities increases with the level of Mother’s
education. Many studies conducted in India (31)(32) and other countries (33)(34) have
found that mother’s education is important determinant of ANC care. High education
standards among women enhance communication with husband and other family
members on health care issues. Kerala has highest literacy rate of 93.91 % resulting
lowest MMR 42 in 2019.while Bihar has lowest literacy rate showing low birth
expectancy at birth and high maternal mortality rate 165 .

CASTE AND RELIGION:

Social factors like religion and caste plays an important role in inequality. The study
found that Muslim women and scheduled caste women are less likely to utilize the ANC
care. (25). A study conducted in rural North India found the widespread caste-wise
inequalities in utilization of anc.(31) In the research of Influence of Socio-Demographic
factors on the Use of Antenatal Care found that Christian are more likely to use
antenatal care than Hindu and Muslims mothers by 52 %. The 45% of women die from
scheduled tribes and 17% from scheduled caste. () who.int/maternal-child-
adolescent/epidemiology/maternal-death-surveillance/case-studies/india-social-
determinants

Age and parity:

Majority (63%) of women dies at very young age( less than 25 years old )and 40% die
at their 1st pregnancy & 8% during their second. With the increase in age and the birth
order, the utilization of full ANC,SBA and PNC goes on decreasing.(25)

Effect of mass media

Mass media has always a big role in educating people. The study has found the
exposure to mass media has positive association with utilization maternal health care
services. The women who are exposed to television about messages on prenatal care
were 3.35 times more likely to use antenatal care than women who were not exposed to
the message on television. Women exposed to newspaper who read messages about
prenatal care were 4.37 times more likely to use antenatal care than women not read
messages about prenatal care in the newspaper (35).
Government policies:

Public health initiatives

icon for the Millennium Development Goal to improve maternal health

Millennium Development Goals,From Wikipedia, the free encyclopedia (Redirected from

United Nations Millennium Development Goals)
From 2000-2015 India participated in the Millennium Development Goal to improve
maternal health. All 191 United Nations member states, and at least 22 international
organizations, committed to help achieve eight Millennium Development Goals by 2015:
(36)

1. To eradicate extreme poverty and hunger
2. To achieve universal primary education
3. To promote gender equality and empower women
4. To reduce child mortality
5. To improve maternal health
6. To combat HIV/AIDS, malaria, and other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development
9. To improve maternal mortality rate and overall maternal health, India has taken
numerous collaborative efforts.
Also, Government of India adopted the Reproductive, Maternal, New-born, Child and
Adolescent Health (RMNCH+A) framework in 2013, It essentially aims to address the
major causes of mortality and morbidity among women and children. This framework
also helps to understand the delays in accessing and utilizing health care services

Based on the framework, comprehensive care is provided to women and children

through five pillars or thematic areas of reproductive, maternal, neonatal, child, and
adolescent health. The programs and strategies developed by various divisions are
guided by central tenets of equity, universal care, entitlement, and accountability to
provide ‘continuum of care’ ensuring equal focus on various life stages.(37)

So far, the significant achievement is that the Maternal Mortality Ratio (MMR) for the
period 2014-16 is 130maternal deaths per 100,000 live births.( According to the latest
figure released by Registrar General of India - Sample Registration System (RGI-SRS)
With this, India has achieved the Millennium Development Goal (MDG) 5 i.e. India have
achieved a reduction in MMR by three quarters between 1990 to 2015. The target was
to achieve 139 maternal deaths per 100,000 live births.(38)

Areas of work:

To improve inequality GOI choose following areas of work:

Quality Ante Natal care: Quality and comprehensive ANC incorporates minimum of at

least four ANCs including early registration and first ANC with first trimester. The ANC
package includes physical and abdominal examinations, Hb estimation, screening for
Gestational Diabetes Mellitus, Thyroid disorders, HIV/Syphilis and urine investigation,
T.T/Td, Immunization, distribution of IFA tablets & Calcium (6 months during Antenatal
period & 6 months during postnatal period) and counseling for nutrition etc.  Early
detection of high-risk pregnancies, follow up and management are important component
of Antenatal care.
Essential Obstetric Care during Delivery: Government of India provide free
institutional delivery at its network of health facilities including Sub-centre, primary
health centres, community health centres, sub-district hospital, districts hospital etc, to
reduce maternal &neonatal morbidity and mortality. Government of India is
operationalizing the 24 X 7 PHCs services and providing training to SNs/LHVs/ANMs
under Skilled Attendance at Birth.

Post natal care for Mother and New born:-Ensuring post-natal care within first 24
hours of delivery and subsequent home visits on 3rd, 7th, 14th and 42nd day is the
important components for identification and management of emergencies occurring
during post-natal period.  The ANMs, LHVs, and staff nurses are being oriented and
trained for tackling emergencies identified during these visits

Provision of Emergency Obstetric and Neonatal Care at FRUs:

Provision of Emergency Obstetric and Neonatal Care

critical components such as manpower, blood storage units and referral linkages.

Availability of trained manpower (Skill Based Training for health care providers) is
linked with operationalization of FRUs. The initiation like training programmes to
overcome skilled manpower, 18 Weeks Training Programme of MBBS Doctors in Life
Saving Anaesthesia Skills (LSAS) for Emergency Obstetric Care,16 weeks Training
programme of MBBS Doctors in Obstetric Management Skills including C-Section, in
collaboration with Federation of Obstetric and Gynaecological Society of India.
(EmOC),10 days Training Programme in Basic Emergency Obstetric Care for Medical
Officers (BEmOC),3 weeks Training Programme for ANMs/SNs/LHVs as Skilled Birth
Attendants (SBA) Referral ,Skills Labs (Daksh training)– For improving the skills of
healthcare providers and to enhance their capacity for providing quality RMNCH +A
services, Government of India established National and State Skills Lab.

Referral Services at both Community and Institutional level-GOI has introduced

Basic patient care transportation through ambulances with an aim to reach to the  
beneficiary in rural area for quick service delivery ,which includes  different models
including public, private partnership models.

Maternal Mortality and morbidity and prenatal mortality are major public health problems
Majority have an intra partum origin and are a consequence of interventions carried out
around the time of delivery. In light of this, the Government of India, in 2015, developed
‘Dakshata’ for rapidly improving the quality of care during intrapartum and immediate
postpartum period across delivery points in the country. Currently, Dakshata is being
implemented in more than 1500 facilities in seven states of the country. The package
provides the complete set of resources to assist the States in planning and
implementing the Dakshata programmes.

STRAGIES AND INTERVENTIONS:

GOI has implemented following programmes:

1)JananiSurakshaYojana (JSY): JananiSurakshaYojana (JSY), a demand promotion
and conditional cash transfer scheme was launched in April 2005 with the objective of
reducing Maternal and Infant Mortality. It is being implemented with the objective of
reducing maternal and neonatal mortality by promoting institutional delivery among poor
pregnant women.

2)Janani Shishu Suraksha Karyakram(JSSK): Government of India has launched

JananiShishuSurakshaKaryakaram (JSSK) on 1st June, 2011, which entitles all
pregnant women delivering in public health institutions to absolutely free and no
expense delivery including Caesarean section. The initiative stipulates free drugs,
diagnostics, blood and diet, besides free transport from home to institution, between
facilities in case of a referral and drop back home.

3)Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Carrying forward the vision of
our Hon’ble Prime Minister, the Pradhan Mantri Surakshit Matritva Abhiyan was
launched in 2016 to ensure quality antenatal care and high risk pregnancy detection in
pregnant women on 9th of every month.

4)Arogya poshan and LaQshya: In order to further accelerate decline in MMR in the
coming years, union ministry of youth and family welfare has recently launched
'LaQshya - Labour room Quality improvement Initiative. LaQshya program is a focused
and targeted approach to strengthen key processes related to the labour rooms and
maternity operation theatres which aims at improving quality of care around birth and
ensuring Respectful Maternity Care.

5)Comprehensive Abortion Care Services: Comprehensive and safe abortion services

are provided at public health facilities including 24*7 PHCs/ FRUs (DHs/ SDHs /CHCs)
including the Delivery Points.Supply of Nischay Pregnancy detection kits to sub centers
for early detection of pregnancy is undertaken .Capacity Building of Medical officers is
being carried out routinely in safe MTP Techniques. ANMs, ASHAs and other field
functionaries are trained to provide confidential counseling for MTP and promote post-
abortion care including adoption of contraception. Routine orientation and training of
ASHAs to equip them with skills to create awareness on abortion issues in the
community and facilitation of women's access to services.

6)District Level Committees (DLCs) have been framed and empowered for accreditation
the facilities for conducting safe abortion services under MTP Act including approval of
private and NGO sector facilities for conducting MTPs. Regular monitoring and
evaluation of the services are being conducted. Provision of RTI/STI services: Under
NHM, provision of STI/RTI care services is an important strategy to prevent HIV
transmission and to promote sexual and reproductive health services in all the FRUs,
CHCs and at 24 X 7 PHCs.

7)Village Health and Nutrition Day: Village Health & Nutrition Day (VHNDs) are being
organized at Anganwadi center atleast once every month. It is a platform to provide ante
natal/ post partum care for pregnant women, promote institutional delivery,
immunization, Family Planning & nutritional counseling.

8)Newer Interventions: Midwifery - Government of India has initiated midwifery services

throughout the country in 2018, with an objective to provide access to quality maternal
and neonatal health services, to promote natural birthing, to ensure respectful care and
to reduce over medicalization. The Midwifery services initiatives aim to create a cadre
for Nurse Practitioners in Midwifery who are skilled in accordance to ICM competencies,
knowledge and capable of providing compassionate women – centric pregnancy care.

For the improvisation of infrastructure all delivery points are strengthened with
trained and skilled human resources, infrastructure, equipment, drugs and supplies,
referral transport etc. for providing quality & comprehensive RMNCH (Reproductive,
Maternal, and Neonatal& Child Health) services. tertiary care facilities is being
conducted across country to handle complicated pregnancies and MCH Wings - State
of the art Maternal and Child Health Wings (MCH wings) have been sanctioned at
District Hospitals/District Women’s Hospitals and other high case load facilities.

Maternal Death Surveillance and Response(MDSR): The process of maternal death

review (MDSR) has been implemented & institutionalized by all the States since
2017.The States are reporting deaths along with its analysis for causes of death.

RCH portal / MCTS Portal: Name Based Tracking of Pregnant Women and Children has
been initiated by Government of India as a policy decision to track every pregnant
woman , infant & child upto 5years of age by name for provision of timely ANC,
Institutional Delivery, and PNC along-with immunization & other related services.

MCP Card: Ministry of Health & Family Welfare and Ministry of Women and Child
Development (MOWCD) has been launched as a tool for documenting and monitoring
services for antenatal, intranatal and postnatal care to pregnant women, immunization
and growth monitoring of infants.
specific efforts should be made to provide basic maternal healthcare services to the
women of lower socio-economic status. Both the education levels and wealth are
positively associated with the utilization of ANC, SBA, and PNC, and hence economic
and educational improvement of the poor mothers would have a positive effect on
reducing the prevalent inequalities.

The exposure to mass media is the largest contributor to the inequality, and hence there
is a need for wide dissemination of mass media in rural parts of the country. Not only
exposure to mass media, but the public health system in terms of infrastructure, human
resources, and management needs to be upgraded as exposure to mass media will
soon be followed by the widespread utilization of maternal healthcare services.

Mother’s education is another factor that is contributing highly to the inequalities in the
utilization of maternal healthcare services. There is a need to disseminate the
importance of women’s education in rural parts of India as despite having access to the
schooling parents does not deem it necessary to educate their daughters.

The state-wise difference is huge in utilization of maternal health care services.

Specially, north-eastern states like Uttar Pradesh, Bihar, and Jharkhand needed to take
more impressive measures and actions and extra efforts to overcome the current
problems apart from available policies and programmes.(39). It is expected that the key
strategies adopted under National Rural Health Mission (NHM) would improve the
overall quality of health services in India as a whole, it failed to bring equality in the
states of India in terms of service delivery.