By Pooja Badarinath, Senior Programme Officer, ARROW
The Millennium Development Goals had a lofty and laudable goal of reducing maternal mortality ratio (MMR) by three quarters (MDG 5a) and the provision of universal access to reproductive health by 2015 (MDG 5b). In order to show that the number of deaths during childbirth had reduced, the focus of the MDG’s saw a shift towards “delivery” as opposed to a more holistic focus on the situation of women and adolescent girls before and after childbirth and abortion.
However, MDG5 highlighted reproductive health, an issue that had traditionally not been prioritised by the States. A decade after the the MDGs, Continuum of Care (CoC) was highlighted by the Partnership for Maternal and Neo-Natal and Child Health (PMNCH) and the UNICEF as a core principle which all programmes aiming to address maternal mortality should follow.
CoC includes care before pregnancy such as contraception/family planning services, education and empowerment for adolescent girls; care during pregnancy and immediately after delivery, and care after pregnancy when complications may arise for mother and child, as well as the onset of menopause. CoC also accounts for the impact of long distance travel time, financial constraints, poor communication and transport, weak referral links, and at times, low quality care in health facilities. However, a key component missing was the quality of care being provided.
In this context, the Women’s Health and Rights Advocacy Partnership (WHRAP) – South Asia – an international partnership with a regional voice, calls for a context-specific and ‘Rights Based Continuum of Quality Care” (CQC) for women’s reproductive health. WHRAP – South Asia, formed in 2003, has facilitated and contributed to processes aimed at improving the quality of life of marginalised women in South Asia, through strengthened civil society engagement and by demanding accountability for health governance.
CQC is a rights-based framework. It follows from the basic tenet that health is a fundamental right of all people and it is the obligation of the States to ensure that everyone has the highest attainable standard of physical and mental health. This includes reproductive health and rights of all women and girls.
Ensuring a life cycle approach of Quality Care across a woman’s life from preconception and pregnancy to postpartum/post-abortion and menopause and across various locations, e.g., home, community, and health facility – is important to reduce adolescent, maternal, newborn and child mortality and morbidity and improve women’s reproductive health. 
This automatically begs the question, how is CQC different from CoC? The fundamental difference between the two is the emphasis on quality . Quality healthcare goes beyond providing infrastructure and facilities, it includes cost, types of medicines, attitude of practioners – in essence ensuring dignity and respect for women and girls while providing health care.
Quality also mandates a non-acceptance of stigma and discrimination faced by marginalised women. At the same time CQC requires that the context in which women live be a key factor in the design and implementation of programmes and policies that provide health service. In other words, the lived realities of the most marginalised women in the country should inform the programmes.
Reduction of maternal mortality and morbidity is not a single step process. In every society, people’s health care is not only about the presence or absence of health facilities. Social determinants including poverty, educational status, economic status, gender based discrimination and other factors impact health outcomes. In South Asia for an example, caste, class, religion, race and disability among others play a major role in adversely impacting the health of women and girls. These multiple marginalizations do not manifest alone, they interact and intersect with each other in life. The CQC framework needs policies and frameworks that consider marginalisation in its entirety, the way it plays out in real life and not just on paper.
CQC highlights quality care at both home and institutions. However, with the onset of the MDGs, the attention has been on institutional deliveries. In all the four WHRAP – South Asia countries, home deliveries are a reality despite the increase in institutional deliveries. There is now evidence proving that a large proportion of newborn deaths and disease can be reduced by implementing simple, low–cost interventions during delivery and in the vulnerable postpartum period, both in facilities and at home. Furthermore, evidence suggests that the quality of care has suffered in institutions because of the inability of the staff to absorb an increasing number of deliveries. Hence in these contexts it is essentially to tap into the existing systems and train the functionaries within those systems including the traditional birth attendants (TBA). The focus on institutional delivery is slowly eroding the existing support systems, making women more vulnerable, needing to travel further and increasing barriers to ensure a safe and quality treatment.
Another important element of CQC is the recognition of adolescence as a significant period of woman’s life. Consequently, the need to have specific strategies to address the reproductive health needs and requirements of adolescence. This necessarily includes empowerment of adolescent girls and also providing them with information on their bodies, reproductive health, contraception methods etc., i.e. comprehensive sexuality education. 
In South Asia, almost 1 in 3 adolescent girls are currently married or in union and 22% of adolescents give birth before the age 18. Anaemia is one of the primary contributors to maternal mortality (20-25%) and is significantly associated with a compromised pubertal growth spurt and cognitive development among girls aged 10-19 years in South Asia. Further, over 60% of South Asian women of childbearing age are underweight and malnourished. Nutrition is directly linked to food availability, which is directly linked to cost. However, cost is extremely affected by the agricultural policies and trade mechanisms. CQC hence advocates for all these factors to feature in programmes and policies, and not have myopic trajectory which assumes everyone everywhere is the same.
All these elements of quality care can function only if there is a sound accountability system, especially with regard to implementation. And good governance should include budgetary allocation for health care. For an instance, Out-Of-Pocket or self financing is the largest source of healthcare financing in South Asia which implies that quality health care is a luxury accessible to those who can afford it. A study of three large scale privatization initiatives in service delivery, management and capacity building functions in the health sector revealed that privatization in Pakistan’s health sector is not delivering good quality, comprehensive reproductive health services. 
The MDGs came to an end in 2015 with most countries yet to achieve many of their targets. The Sustainable Development Goals (SDGs) that followed are ostensibly more rights-based and holistic. However, the SDGs too have a lofty target of reducing global MMR to less than 70 per 100,000 live births (Goal 3.1) and to ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes by 2030 (3.7).
The indicators to measure success within these targets should be rights based and context specific. These indicators should not only measure live births but also the quality of healthcare that women and girls receive throughout their life. Programmes and policies designed to achieve these goals should be holistic and must adopt a lifecycle approach to provide context specific quality health care. These targets can be actualised only if the policies and programmes to are designed for the betterment of women and girls’ lives as opposed to a box that needs to be checked in a form. The CQC provides a framework which can be applied to ensure that quality healthcare is a reality for every woman and girl.
The author thanks Nalini Singh for her input into an earlier draft.
For more details on CQC and recommendations please refer to: Fulfilling women’s right to continuum of quality care; Context specific, Rights Based Continuum of Quality Care for Women’s Reproductive health in South Asia. You can also email [email protected]