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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 88-92 |
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Health-related quality of life: The neglected facet of women's health in India
Pallika Singh, SK Rasania
Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
| Date of Submission | 19-Oct-2021 |
| Date of Decision | 18-May-2022 |
| Date of Acceptance | 27-May-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Dr. Pallika Singh
Department of Community Medicine, Lady Hardinge Medical College, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijcfm.ijcfm_86_21
Quality of life (QoL) is a multidimensional concept and an essential health component that usually includes both positive and negative aspects of life. The measure of health-related QoL (HRQOL) enables health agencies and social partners to address areas of public health importance and formulate policies which eventually demonstrate the impact of health on QoL. Women form an important pillar of society as they are the primary caretaker of children and elders in every country of the world and therefore, the QoL of women determines the health of the next generation and future public health challenges for families, communities, and the health-care system. Providing health services at par with quality is the need of the hour and a very important health goal considering women's health. Poor delivery of clinical care, failure to meet the professional standards of patient care by health-care providers, mistreatment and abuse by health-care professionals, and inequitable delivery of care are some of the key issues in the delivery of quality maternal health-care services in India and therefore primary health-care professionals should be made familiar with the concept of the HRQoL in the community they are serving. Indian health-care systems need to address to the inequalities and taking off the consumer-centric, market approach of privately run corporate health facilities along with setting up of accountability of all the stakeholders to provide quality care, especially in the government-run facilities and creating a promising environment in health care for women focusing on pregnant and postpartum mothers.
Keywords: Accountability, health-related quality of life, maternal health, mistreatment and abuse, postpartum depression, postpartum women, quality assurance, quality of life
How to cite this article:
Singh P, Rasania S K. Health-related quality of life: The neglected facet of women's health in India. Indian J Community Fam Med 2022;8:88-92 |
How to cite this URL:
Singh P, Rasania S K. Health-related quality of life: The neglected facet of women's health in India. Indian J Community Fam Med [serial online] 2022 [cited 2023 Jun 4];8:88-92. Available from: https://www.ijcfm.org/text.asp?2022/8/2/88/366554 |
| Introduction | |  |
Quality of life (QoL) is a multidimensional concept. It has emerged as an essential health component that usually includes subjective evaluations of both positive and negative aspects of life.[1] Health is one of the most important domains of overall QoL along with education, finance, culture, values, spirituality, morbidity, and life expectancy, thereby adding to the complexity of its measurement. The concept of health-related QoL (HRQOL) has evolved since the 1980s which on the individual level, includes physical and mental health including health risks and conditions such as mortality and morbidity, functional status, social support, and socioeconomic status. On the community level, public health policies, resources, and practices influence populations' health perceptions and thereby influence public health. HRQoL also enables health agencies and social partners to address areas of public health importance and formulate policies which eventually demonstrate the impact on the quality.
Women form an important pillar of the society as well as a family and therefore maternal health care must be safe, effective, timely, efficient, equitable, and people-centered. They are the primary caretaker of children and elders in every country of the world, supporting their households and communities in achieving food and nutrition security and improving livelihood and overall well-being which makes their health a topmost priority. Women's health care and its quality not only determine the health of the next generation and future public health challenges for families, communities, and the health-care system. Improving the well-being of women is an important public health goal for India as it has been researched and improved on ever since in the history of medical science.
The present study is a narrative review aimed at describing the HRQOL of postpartum women focusing on the state of maternal health in India and the world with a purpose of consideration of various factors and initiatives taken and required for better Health-related quality of life of women.
| Maternal Health Focus | | |
Globally, about 800 women die every day of preventable causes related to pregnancy and childbirth and 20% of these women are from India. India's maternal mortality rate although reduced from 212 deaths per 100,000 live births in 2007 to 167 deaths in 2013 to 130 per 100,000 live births in 2016, still faces a draconian challenge of providing basic quality health care to women where annually, estimated 44,000 women die due to preventable pregnancy-related causes. A test put forth by the nation to achieve the Sustainable Development Goal (SDG) target of a maternal mortality ratio below 70 by 2030 and only three states have been able to meet the target to date, Kerala, Maharashtra, and Tamil Nadu.[2]
The National Health Mission (NHM) launched in 2005 was substantial in increasing the number of institutional deliveries in the country. Improvements came largely due to the key interventions on safe motherhood and child health such as the Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakaram (JSSK) scheme under the National Rural Health Mission which encompasses free maternity services for women and children, a nationwide scale-up of emergency referral systems, management of health services at all levels, maternal death audits, and development of maternal death review, surveillance, and response process. Furthermore, access to family planning methods is not only a human right but it also proved to be extremely important for individual and societal well-being and nation's development as a whole.[3]
The India Newborn Action Plan (INAP) which came up in 2014 laid out a vision for India to end preventable newborn deaths and stillbirths and accelerate progress with high-impact and cost-effective interventions. This initiative defined the six pillars of intervention, i.e., preconception and antenatal care, care during labor and childbirth, immediate newborn care, care of healthy newborn, care of small and sick newborn, and care beyond newborn survival. Each of these interventions would undoubtedly lead to the better QoL of mothers as well as their children and families.
A strategic initiative, DAKSHATA was also launched by the Government of India in 2015 for empowering providers for improved maternal and neonatal health care during institutional deliveries and to strengthen the quality of care for pregnant and postpartum mothers. In November 2016, the Government of India also launched the Pradhan Mantri Surakshit Matritva Abhiyan with an aim to provide comprehensive care and quality antenatal care on the 9th day of every month during the second and third trimesters of pregnancy and to track high-risk pregnancies. Moreover, in another attempt, the Government of India launched LaQshya, a labor room quality improvement initiative in 2017 under the NHM to reduce preventable maternal and newborn mortality, morbidity, and stillbirths associated with providing quality care around delivery in the labor room and operation theaters along with respectful maternity care.
| Importance of Health-Related Quality of Life in Present India | | |
Providing health services at par with quality is the need of the hour and a very important health goal. Research and analysis of QoL and its determinants can identify areas with poor perceived health and identify needs for health policies and legislation as interventions to improve their situations as well as resource allocation based on the unmet needs of the community and avoid more serious consequences to health. At the same time, a need to familiarize primary health-care professionals with the concept of the HRQoL in the community they are serving is rising as quality in itself is a very subjective arena. This would eventually help the policymakers to plan responses and for resource allocation according to the needs that arise in the community and to evaluate the impact of the actions taken.
| Key Issues in Delivery of Quality Maternal Health-Care Services in India | | |
The quality of services provided to the mothers during pregnancy and postpartum period is below the substandard levels barring some states.
- Poor delivery of clinical care with the rationale use of drugs and treatment according to the standard guidelines is still farfetched
- Nonavailability of skilled nurses working in labor rooms of health facilities or the auxiliary nurse midwives at subcenters. The skilled birth attendants are either not trained or the quality of training is usually suboptimal with poor skill development and these practices lead to poor quality of care being provided which, thereby affects the QoL in pregnant females as well as postpartum mothers and their children
- Failure to meet the standards of patient care by health-care providers and professionals along with lack of informed consent and confidentiality damage the rapport. Listening to the complaints of the pregnant mothers attending antenatal clinics is least considered looking at the everyday rush in the outpatient departments (OPDs), especially in the tertiary care centers
- Inadequate services in the form of failure to provide hygiene and sanitation is a major issue faced in the Indian health facilities which equally accounts for poor quality standards wherein providing clean washrooms in labor rooms, OPDs, and maintaining hygiene in the examination area is still a challenge faced by a majority of women receiving antenatal, natal, and postnatal care
- Mistreatment and abuse by health-care providers and professionals along with a lack of respect, empathy, and lack of privacy when seeking care during labor and childbirth impact the HRQOL as well as the quality of care across all levels and dimensions. Abuse is reported in many forms as in verbal, physical, and sexual abuse, discrimination due to poor financial status, and stigma in cases of diseases such as HIV. The use of harsh language, threats and use of force in labor rooms, as well as OPDs of public hospitals, is more pronounced
- Easy access to safe abortion services for women is still a challenge today which affects the QoL of women. The World Health Organization has stated that “every 8 min a woman in a developing nation will die of complications arising from an unsafe abortion.”[4] An estimated 15.6 million abortions occur annually in India. Only 5% of abortions in India occur in public health facilities, which are the primary access point for health care for poor and rural women.[5] Unsafe abortions account for 14.5% of all maternal deaths globally[6] and are most common in developing countries in Africa, Latin America, and South and Southeast Asia, with restrictive abortion laws, while the unmet need continues to be high. Such abortions are preventable by ensuring access to quality family planning, safe abortion, and counseling services as well as by providing comprehensive sex education[7]
- Inequitable delivery of care with health system conditions and constraints plays a major role in affecting the QoL in postpartum women. An unbalanced share of facilities in urban settings hinders access to care among that living in rural areas where most of the population of India resides. Furthermore, mothers with lower income and literacy, and from tribal groups, scheduled castes, and rural areas face more discrimination as compared to the other counterparts
- Setting up accountability for providing high-quality health-care services is another critical dimension for improving the quality of care. The absence of a framework to measure and monitor the QoL, affected by lack of supervision, frequent shortage of essential commodities, and human resources is a major concern too.
| The Quality Gaps and Policy Mismanagement | | |
Spending on health care in India is among the lowest in the world with just over 1% of the Gross Domestic Product, along with many shortcomings related to workforce, infrastructure, and the quality, availability, and affordability of health services. Despite providing the high quality of health services, if women are mistreated, abused and demeaned, demanded money during the process of delivery, the pregnant mother as well as their families and their caregivers will avoid and delay utilization of medical care as much as possible, thereby disfiguring the high-fetched goals of women health care and empowerment.
According to the National Family Health Survey-4, with safe motherhood initiatives by the Government of India, nearly 80% of pregnant women received institutional care at the time of childbirth, but despite so much efforts in policy formulation and implementation and execution, persisting high rates of mortality indicate inadequacies in the quality of care provided in these health facilities and policy formulation and implementation failures.[8]
The risk of maternal and newborn mortality is disproportionately high during childbirth and the majority of the causes of mortality are preventable through appropriate care of mothers during labor and birth. Expanding coverage of health services and ensuring affordability and accessibility are insufficient without improving the quality of care and ensuring HRQOL. The fact of the matter is that the purpose of Universal Health Coverage (UHC) might fail to achieve its key objective of providing better health unless patients have access to quality services that meet the quality assurance standards and guidelines as UHC should not only include health care and insurance, it should also ensure the quality of health services as well as the QoL to everyone who needs it.
In 2017, around 810 women died every day from preventable causes related to pregnancy and childbirth globally where 94% of these maternal deaths are transpired in low and lower-middle-income countries as women fail to get quality maternal care. Currently, about 122 women in India die from complications for every 100,000 live births. Looking at SDG-3 and target 3.1 to reduce the global maternal mortality rate to <70/1,00,000 live births by 2030, the focus needs to increase toward improving quality to avert maternal deaths.[9] The study published in 2015 in Uttar Pradesh highlighted that infrastructure, human resources, supplies, and medicine as priority areas of quality improvement in the facility as perceived by both users and providers, nevertheless, the interpersonal aspect of care primarily reported by the users must also not be ignored.[10]
In line with the global evidence on the importance of skilled care at birth, the Government of India, over the past decade, has focused on increasing institutional delivery through programs such as JSY and JSSK. As a result, the country has experienced an unprecedented increase in institutional deliveries in public health facilities, but the quality aspect still falls behind the set objectives.
| Recommendations and Way Forward | | |
The prevalence of deteriorated HRQOL is high, where disrespect and abuse of women during pregnancy and childbirth account for a major concern as it occurs at all levels of interaction between the women and the health-care professional. Strengthening of quality improvement and sustainable quality assurance mechanisms is major problem-solving steps in improving access to health care and achieving “Health for All” agenda and is absolutely critical for India to achieve its SDG target of reducing maternal mortality. QoL and demand for quality care are the missing links in the Indian scenario these days. Setting up of quality improvement models starting from the subcenter levels to the tertiary care hospitals to improve the clinical and quality standards. Quality of care certification for both private and public sector hospitals should be made mandatory for all health-care facilities in India. Increasing the coverage, not only clinical standards but also including strict quality standards for maternal and child health services being provided. Trained health-care workers with skilled technical support staff with regular availability of equipment and logistics management would ensure greater quality and persistence toward achieving the SDGs by 2030.
Involving organizations for quality certification such as MSD for mothers which is being done in states such as Uttar Pradesh, Jharkhand, and Rajasthan on efforts with the Federation of Obstetric and Gynaecological Societies of India and the Johns Hopkins Program for International Education in Gynaecology and Obstetrics to provide Manyata certification for high impact based quality care to pregnant and postpartum mothers. To improve conditions, the following recommendations become necessary, namely: Quality assessment through screening and rapid assessment of all complications, deaths, and disabilities during all stages of pregnancy and after delivery. Safe and clean delivery practices with efficient newborn care in view of the INAP. Consent taking practices and ensuring respectful and supportive care to pregnant mothers with adequate postpartum care to the mothers with counseling to primigravida mothers at least till 42 days of the postpartum period. Also a regular review of indications of cesarean sections especially at private health facilities should be made mandatory.
Capacity building of health-care providers for improving interpersonal communication skills and maintaining a sensitized approach along with active participation of women in their own quality care. At large, the availability of resources as well as interpersonal communication both determines the satisfaction of mothers availing health services. Normalization of mistreatment and abuse by health-care professionals is in itself a roadblock in achieving the aims of women's reproductive rights and empowerment. Achieving sustainable health through investment and research-based approach in improving quality of care which will thus effectuate in achieving UHC for comprehensive reproductive, maternal, and newborn health care with special focus on high burden states or the Empowered Action Group states of India. The paucity of information and literature in the Indian context regarding HRQoL of pregnant and postpartum women is a major drawback and requires urgent attention.
Indian health-care systems need to address the inequalities, especially financial disparities where people belonging to poor socioeconomic status suffer a lot of discrepancies, therefore making it affordable and accessible to quality of reproductive, maternal, and newborn health and ensuring accountability to improve quality of care. Addressing and reporting all causes of maternal mortality in maternal death review surveillance and reproductive and maternal morbidities, and related disabilities and strengthening health systems to collect high-quality data to respond to the needs and priorities of pregnant and postpartum women.
In India, giving patients a voice and making sure that the providers listen will become all the more important in the coming years. Efforts to improve the QoL with good facility care, the focus should turn on government-funded hospitals largely as most of the health-care services utilization is through the government sector as the issues faced are massive due to the load of patients, especially in the tertiary care hospitals, whereas the primary centers suffer due to lack of infrastructure essentially. The privately run corporate health facilities usually follow a consumer-centric and market approach in the metro cities where, most of the time charging large amounts of money for irrational treatments and drugs of which the patient is usually unaware of, thus, putting a financial burden with large out-of-pocket expenditure on families is a matter of concern. This requires strict vigilance and monitoring with a strong, effective grievance redressal and feedback mechanism through various digital platforms and innovations to enable women to choose affordable, quality maternal health care, and to pay heeds to the major issues faced by them utilizing private and public health-care services. With an aim of providing UHC for its population, a strong political will along with a national health-care protection scheme – Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, offers a unique opportunity to accelerate the delayed progress toward an important milestone of decreasing maternal mortality rates in India by providing a health cover to females belonging to poor and vulnerable families for secondary and tertiary care hospitalization during and after pregnancy.
Accountability of all the stakeholders to provide quality care to the pregnant mothers and consider improvement in the QoL. A multipronged approach is needed to address to the issues and also consider the above recommendations of quality of care during the intra and immediate postpartum period. Special emphasis should be given on various competencies and successful initiatives in reproductive health care and help create a promising environment at the healthcare facilities for the pregnant and postpartum mothers for improved quality of life. Promoting the use of family planning services is also significant in improving maternal health and should be made a provision of quality of care as higher levels of contraceptive uptake and decreasing the unmet needs are still a challenge in various high burden states in India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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