What Women Want: A Q&A with Dr. Aparajita Gogoi

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What do women want? It’s a simple yet complicated question. At the most basic, women want – and deserve – the fundamental right to live a healthy and safe life. And at the core of this is access to quality and respectful healthcare at all levels – including during pregnancy and child birth.

Despite progress made to reduce maternal and newborn mortality rates, roughly 300,000 girls and women still die due to pregnancy related complications every year. India represents 15% of maternal deaths worldwide with an estimated 44,000 women dying each year from pregnancy related causes.

With a vast range of clinical interventions and health services available to reduce these rates, what can be done to ensure quality of care for women around the world? One way is to ask What Women Want through community dialogues and public hearings.

This month, Deliver for Good seeks to tackle this topic in a conversation between Susan Papp, Managing Director of Policy and Advocacy at Women Deliver, and Dr. Aparajita Gogoi, National Coordinator of White Ribbon Alliance India. This conversation builds on a study that Susan and Aparajita published together on the role of public hearings to improve maternal health in India—it is also linked to a new campaign that both organizations have teamed up on to launch recently.  As a passionate advocate for safe motherhood and a renowned influencer of maternal healthcare policy, Dr. Aparajita Gogoi is at the forefront of global efforts to improve maternal and newborn health for all.

Susan Papp: India’s maternal death rate is estimated at 167 deaths per 100,000 live births. You were recently quoted saying that 80% of those deaths are due to preventable causes – what are some specific actions we can take to prevent those deaths? 

Dr. Aparajita Gogoi: Over 80 percent of maternal deaths are due to six causes: haemorrhage, eclampsia, obstructed labor, sepsis, complications arising due to unsafe abortion and pre-existing conditions such as anemia, malaria, etc. Most of these can be treated in a hospital or First Referral Unit with the necessary emergency facilities and skilled personnel for obstetric care.

While it is known that maternal deaths can largely be prevented by adhering to some basic health interventions – like improving access to skilled care and emergency obstetric care, and ensuring access to the family planning services that allow women to choose if, when and how many children they will have –  we must also tackle the underlying causes for maternal mortality like low economic status of women, low literacy of women, lack of decision making powers and early marriages. Delaying marriage and first pregnancy and preventing unwanted pregnancies through informed protection is extremely important, in addition to creating a positive social environment by educating families and communities on care for pregnant women, teaching them to recognize danger signs during pregnancy, ensuring that they make arrangements for finances and transportation and identify health facilities with essential obstetric care in case of an emergency.

Susan Papp: Health workers play a critical role in delivering quality and respectful maternity care. Unfortunately, in low-income countries, only 51% of women have a skilled healthcare provider present during child birth which compromises the quality of care and leads to both maternal and newborn death.  Why is quality of care an ongoing problem and what can be done to strengthen health systems -- including increased health worker capacity – to deliver quality, safe, and dignified care during pregnancy and childbirth?

Dr. Aparajita Gogoi: Quality of Care (QoC) is increasingly recognized as a critical aspect of the maternal and newborn health agenda, mainly with respect to care during labour and delivery and in the immediate postnatal period. High coverage alone is not enough to reduce mortality. To reduce maternal and neonatal mortality substantially and to move towards the elimination of preventable causes of maternal and newborn death, increased coverage should be accompanied by improved quality throughout the continuum of care.

In a health system, quality broadly encompasses clinical effectiveness, safety and a good experience for the patient and implies care which is effective, patient-centred, timely, efficient and equitable. Improving QoC in maternal health cannot be a vertical change but rather a  diagonal change involving improved reproductive health care as well as the quality of the overall health system. We need to find solutions to an inadequate number of health technical and support staff, address shortage of essential drugs, reduce poor/rude attitudes among health workers, reduce high health care costs, eliminate corruption/Illegal payment of fees and improve poor health infrastructure.

Our work also tells us the importance of ‘zero-tolerance’ for all forms of disrespect and abuse in the facilities, since women do not access services for fear of disrespect and abuse. Encouraging other actions like allowing a birth companion to be present with the women during labour and delivery, will also lead to positive outcomes.

Susan Papp: In 2017, the White Ribbon Alliance India launched the ‘Hamara Swasthya Hamari Awaaz’ campaign which means ‘Our Health, Our Voices.’ The campaign directly engaged more than 143,500 women by asking them “What would you want from a health facility for reproductive for the best quality care for reproductive and maternal health services for pregnancy, childbirth, and family planning?” The goal was to provide India’s policy makers and maternal health and rights advocates with data on the most pressing issues around maternal health care.  Why is access to accurate data so important in this work, what gaps were filled by this initiative, and which gaps remain?

Dr. Aparajita Gogoi: There is growing evidence confirming that patient’s perception of quality of care and satisfaction with care is critical to the utilization of health services. Perceived quality is a key determinant of utilization and user satisfaction is the ‘patient’s judgment on the quality and goodness of care’. Quality of care has an impact on whether and where women seek care. Women are willing to travel further to reach a clinic that provides better quality care. Given that a woman’s perception of the quality of care she receives during labor and delivery is likely to influence her decision about whether to seek facility-based health care, it is important to look at what quality of care means from the individual woman’s perspective.

While accessing quality care, most people focus on measuring facility infrastructure, human resources, and safety measures. But few assess the quality of care from women’s perspective. And few examine aspects of care such as how the woman was treated by facility staff, whether care was given in a timely fashion, or whether the facility was clean.

The  ‘Hamara Swasthya, Hamari Awaz’ campaign implemented by the White Ribbon Alliance, India, kept women in the center and reached out to women directly to understand what they needed for quality maternal healthcare in India.   The campaign reached about 1,43,556 women across the country and provided a platform for their voices to be carried to the highest rungs of the government.   'Asks' submitted by 1,43,556 women from across India were analysed with the  findings indicating that 36% of women have asked for access to maternal health entitlements, services and supplies, followed by 23% women who seek services provided with dignity and respectful care. This implies that about 4 out of every 10 women registered their asks for access to maternal health services such as free medicines and medical examinations, access to blood banks, post-natal care etc. 20% of the women seek availability of health providers while 16% seek clean and hygienic health facilities.

This campaign returned to us an understanding of women’s priorities at a very important time in their lives and allowed us to collate these answers and aggregate them for incorporation into programs.

Susan Papp: The program in India was deemed a big success and White Ribbon Alliance recently adapted it for a global campaign known as “What Women Want” which sets out to interview one million women and girls worldwide—from capital cities to rural villages—about their top priority for quality maternal and reproductive health services.  How and why does White Ribbon Alliance prioritize engaging girls and women in the programs and policies that affect their lives? What lessons can other organizations learn from this?

Dr. Aparajita Gogoi: White Ribbon Alliance in India (WRAI) understands that women, especially those living in rural areas of the country, face multiple challenges with maternal healthcare services. It is therefore important to engage women directly and understand the change they would wish for in terms of a better maternal healthcare service, routing towards equity and dignity for all women. Engaging directly with girls and women around the globe will help governments, health professionals, private providers and civil society organizations to better understand their realities, issues and demands thus ensuring maternal health policies and programs are designed to address them. 

These kinds of data, generated directly from citizens, can help push issues to the top of the political and media agendas because they reflect a woman’s reality. Such data provides an opportunity for citizens themselves to identify ways of ensuring the accountable delivery of the  SDGs. Citizens are also forthcoming about providing data on issues that they care about.

Susan Papp: Maternal mortality is often a consequence of gender inequality. What inequalities have you seen that directly impact maternal health care and how can we address them to ensure quality, equity, and dignity for all girls and women?

Dr. Aparajita Gogoi: The death of girls and women during  childbirth are not caused solely by a lack of skilled attendance or health services.  It happens because we do not value the lives of girls and women. Many societies are patriarchal and misogynistic, to the extent that girls are killed before they are born.

The onus of improving women’s health goes beyond just the health sector. Changing gender norms, preventing early marriage and childbirth, improving nutrition, improving education, improving access to information and decision making power, and support from men and other members of the family are equally if not more important. We must shift social norms and practices toward greater respect for and enjoyment of women’s equal rights.  Evidence shows the interconnection of other sectors with women’s health which thereby demands cross-sector collaboration if results are to be achieved. In countries with more gender equitable indicators, for example, the Measles, Mumps, Rubella (MMR)  is low.

Child marriages must be prevented - we know that girls who give birth before the age of 15 are 5 times more likely to die in childbirth. We must prevent our girls from becoming mothers-and to do so, and this means ensuring girls complete secondary schooling – which will make them six times less likely to marry early as compared to others who have little or no education. Girls who are out of school are four times more likely to have a child before their 19th birthday. Getting girls to compete secondary education will not only lead to better reproductive health outcomes including increasing use of contraceptives by four times, but economists say if 10% more  girls go to school, it can increase a country’s GDP on average by 3%!!   

Susan Papp: Now that we know about the “What Women Want” campaign – we have to ask… “What is your one request for quality reproductive and maternal health services?

Dr. Aparajita Gogoi:  It is difficult to put forward one specific ask on behalf of the alliance since it has already received asks from 150,000 women. But if we have to narrow down to one specific ask it will be – zero tolerance for disrespect and abuse in health services.