This case study has used the results of a review of literature to understand the persistence of poor maternal health in Rajasthan, a large state of north India, and to make some conclusions on reasons for the same. The rate of reduction in Rajasthan's maternal mortality ratio (MMR) has been slow, and it has remained at 445 per 1000 livebirths in 2003. The government system provides the bulk of maternal health services. Although the service infrastructure has improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health (phase 1 and 2), have attempted to improve maternal health; however, they have not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. Thirty-two percent of women delivered in institutions in 2005-2006. A 2006 government scheme to give financial incentives for delivering in government institutions has led to substantial increase in the proportion of institutional deliveries. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The recent scheme of Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed.
Key words: Delivery; Maternal health; Reproductive health; Skilled birth attendance; India
With a maternal mortality ratio (MMR) of approximately 445 per 100,000 livebirths, the state of Rajasthan contributes significantly to India's burden of maternal deaths (1). The context of Rajashan sets the stage for this high MMR, both in terms of its terrain and the sociocultural environment of women's lives. This paper reviews the context of maternal health in Rajasthan and the development and present status of maternal health services in the state.
With a land area approximating 10% for India, Rajasthan is the largest state in the country. More than 60% of the state's total land area is desert, characterized by extreme temperature, low rainfall, and sparse habitation (Fig. 1). It is also the eighth most populous state of India, with a total population of 56.4 million (Census 2001), three-quarters of which lives in rural areas (Table 1) (2). The decadal growth rate continues to be high compared to other states. Over 90% of the population follows the Hindu faith, followed by 9% Muslims (3). Hindus constitute a larger proportion (95%) in the southern and south-eastern regions. Most working people in Rajasthan are engaged in agriculture and animal husbandry, although the situation in some regions is changing gradually. In areas that are better irrigated, agricultural labour is more common whereas, in the tribal-dominated south of the state, the contribution of agriculture is negligible. Under-employment is widespread, and industrial employment is low (7.5%) (4). The tribal south and the semi-arid north-central regions exhibit high rates of migration for employment; two-thirds of households in the tribal south have reported migration, with nearly half of the family income derived from sources relating to migration (5). Since 1998-1999, Rajasthan has faced regular droughts (except in 2005-2006), especially in the arid western region. With rainfall at less than 30% of the annual average, there has been severe breakdown of the livelihood support-base 6). Since women are responsible for collecting natural resources, such as water, fuel-wood, fodder, and forest-produce, droughts are known to differentially affect them. …