The gap between policy and practice in maternal health

As the UN Special Rapporteur on maternal mortality in India points out there is a 'yawning gulf between ... commendable maternal mortality policies and their urgent, focused, sustained, systematic and effective implementation.' Reproductive Health Matters explores the causes and impact of this gap, but also highlights hopeful signs of progress. Two papers from India included in the issue capture both the good and bad news that characterise the gap between rhetoric and reality in maternal health and maternal mortality. In India a range of provisions to support better maternal nutrition and access to subsidised health care are required by law, but there is a wide gap between policy and practice. Preventable deaths are caused by several factors including a shortfall in antenatal care, delays in emergency obstetric care and inappropriate referral. Detailed case studies of women who died point to lack of accountability, discrimination on the grounds of poverty and caste, and according to Subha Sri Balakrishnan, author of one of the papers, "In some cases...quality of care (that) was so poor that it may be considered negligent." Both papers follow subsequent action taken to seek government accountability and justice. In one paper, author Jameen Kaur, reports on the way in which a women's family sought redress in the courts, supported by human rights lawyers. The second paper details an investigation lead by Subha Sri Balakrishnan into maternal deaths in response to a public protest about local maternal deaths in Madhya Pradesh. The researchers presented their findings to district and state level health officials which led to some improvements in care. Examples of using law to promote accountability and good practice are described in a paper from Latin America reporting on landmark decisions by the UN Committee on the Elimination of Discrimination Against Women (CEDAW) calling for appropriate maternal health care (Brazil) and decriminalisation of abortion to safeguard women's health (Peru). These are promising examples of the application of human rights to demand government responsibility for maternal deaths and to assert the rights of women not to die in pregnancy, childbirth and unsafe abortion. Furthermore a new emphasis on evidence-based practice is described in several papers, providing grounds for optimism. It suggests there is a real desire to improve outcomes and the hope that new initiatives may have a greater chance of success in saving women's lives. Without the political commitment to addressing equity, however, important initiatives will continue to fail the poorest and most marginalised women. As one author notes, "The death of a woman due to pregnancy complications is not just a biological fact it is also a political choice."