For centuries, the handling of childbirth and childcare was considered the domain of midwives and mothers. The second half of the 20th century witnessed a change in thinking. The role of the state in improving the health of people came to the forefront. In the opening years of the 21st century, the millennium development goals placed maternal and child health at the core of the struggle against poverty and inequality, as a human rights issue. With a booming economy and an improved standard of living, no mother should die in the course of the normal process of giving birth. However, more than 500,000 mothers are still dying each year, mostly of avoidable causes (1).

In February 2011, 13 pregnant women died within 12 days in Umaid and MGM hospitals, two government-run specialty hospitals affiliated to a medical college at Jodhpur, Rajasthan (2). Another five maternal deaths took the death toll to 18 in the next nine days (3). Following a public outcry, the government of Rajasthan instituted an enquiry into the matter. Experts from SMS Medical College, Jaipur, conducted the investigation. The report has pinpointed the contamination of intravenous fluid as the probable cause of maternal deaths. The government ordered the arrest of the owner of the IV fluid manufacturing plant, in addition to suspending three other low-ranking health department officials. The next of kin of each woman who died received Rs 5 lakh compensation.

The maternal mortality ratio of India was estimated to be 254 per 100,000 live births for the period 2004-06, a far cry from the national goal (4). The strategy adopted by the government of India through its reproductive and child health programme consists of: quality ante-natal care; essential obstetric care at the domiciliary level, and emergency obstetric care at first referral units. Cash incentives schemes were added later to promote institutional deliveries, viz. Janani Suraksha Yojana (JSY) under the National Rural Health Mission. Institutional delivery rates have been reported as showing a substantial increase since the introduction of the scheme. However, these have not translated into a reduction in maternal mortality ratios. The northern states, Punjab, Haryana, Uttar Pradesh and Rajasthan have not benefited from this intervention, the reasons for which need to be explored (5). Incidents of the kind that occurred at Jodhpur will be a serious setback to the government’s programmes to promote institutional delivery. We need to critically reexamine our preparedness to ensure the safety of the women who come to hospital to give birth in a secure environment.

This incident also opens up several micro and macro level issues for deliberation.

The micro level issues are specific to attending hospital such as quality of care, infection control practices, standard operating procedures, inventory control and medical audit. Quality of care continues to be an issue of concern in public sector hospitals of India. A recent assessment of institutional delivery under the JSY in the neighbouring district of Jaipur states that "quality aspects of institutional deliveries are far from desired level mostly because of lack of resources, both manpower and materials; non achievement of Indian Public Health Standards". The quality of institutional delivery care was found to be better in private hospitals in comparison to public sector hospitals (6:177). Recent initiatives by the government of India, such as the introduction of Indian public health standards for public health institutions at different levels, and opening the doors to national accreditation, have not moved beyond the manuals and booklets.

At the macro level, such occurrences should stimulate introspection into the whole process of manufacturing, and distribution of drugs as well as the quality control at different levels. While the introduction of new drugs or vaccines into the market is governed by the Drugs Controller General of India, the manufacture of drugs is under the ministry of chemicals and fertilisers. India is perhaps the only country in the world where this is the case. Pharmaceutical manufacturers are supposed to comply with good manufacturing practices endorsed by WHO. Little is known about how good these good manufacturing practices are.

Finally, the key question is the preparedness of hospitals to ensure optimum maternal health. It is often said that every maternal death teaches the health system a lesson. How many maternal deaths do we need to witness before our health system becomes wiser and more responsible?