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Maternal Mortality in India

Maternal Mortality in India

Maitreyi Menon

FLAME University
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Maternal Mortality in India

Maternal Mortality Rate is defined as the number of maternal deaths by the total resident live births

for the same geographic area for a specified time period multiplied by 100,000. According to the

World Bank, India’s Maternal Mortality Rate (Referred to as MMR from now on) is 130, well

below the global average of 216. Globally, MMR has declined 44% from a world average of 385

in 1990 to 216 in 2015. India, along with Nigeria, accounts for 1/3rd of the total global maternal

deaths. Within the country, Assam records the highest number of Maternal deaths in India (237)

while Kerala clocks in the lowest (46). Even within a state, some districts have done better than

the others. For instance, in Uttar Pradesh, which is the sixth worst performing state in India, the

Meerut Mandal, located in western UP has an MMR of 151, which is better than the national

average while the Devi Patan Mandal, located towards the south western part of the state had an

MMR of 366, which is comparable to that of Ethiopia and Haiti (Veneman, 2009).

There are four primary causes leading to high MMR in India- barriers to emergency

care, gaps in continuity of care, poor referral practices as well as unaffordability. Ante and

postpartum hemorrhages, anemia, Infections, hypertensive disorders and obstructed labor

account for a large part of maternal deaths worldwide (Campbell, 2001). The structural disparities

in social and cultural indicators can shape health outcomes, and in turn, health inequities.

Analysing the social and economic determinants of maternal health can

improve health outcomes in that domain as well. A study by UNDP developed a framework to

assess the social and economic attributes of maternal deaths (UNDP, 2010). The elements of this

framework are:

1. Individual attributes (Like age, knowledge of services, obstetric history, etc.)


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2. Family characteristics (access to resources, economic status, support from natal and

prenatal

family)

3. Community context (rural-urban disparity, social position- class, caste, ethnicity)

4. Cultural and social norms (women's status, health beliefs, religion)

5. Health services (availability of services, accessibility)

6. Structural determinants (law, policy and budget)

Majority of the women who die are very young, often younger than 25. A large

number of the deceased women in India are rural, backward caste and economically vulnerable.

Almost 45 % of the women who died were from the Scheduled Tribe (ST) community while a

further 17 % belonged the Scheduled Caste (SC) community. Women living in remote hamlets

were especially vulnerable. Often, these communities belonged to Scheduled caste or scheduled

tribe communities, and therefore, health care service providers refused enter these hamlets and

provide services (UNDP, 2010).

Lack of emergency obstetric care, unavailability of blood, inadequate antenatal and

postpartum care and poor referral care contributed to health system failures which lead to maternal

deaths. The lack of availability of blood transfusion services has contributed up to 46% of the

deaths in a documented study conducted by the World Health Organisation in 10 Indian states.

India is only able to collect 9 million units of blood as compared to its 12-million-unit demand.

Especially in poorer states, where almost 50% of the women are anemic and post and ante partum

hemorrhages are the leading cause of maternal deaths, blood transfusion services are necessary

(Kumar, 2010).
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Only 37% of women in India receive post-natal care. This coverage is a serious policy

gap, given that absence of postpartum care is one of the main reasons for poor maternal

outcomes. One of the main reasons for this is the lack of skilled workers. Around 50% of

community health centers, and 30 % of First Referral Units (FRU) do not have anesthetics and

obstetricians. Even though there has been an expansion of rural health infrastructure in the previous

decades, the country’s rural health infrastructure is not adequately examined and evaluated. For

instance, a large percentage of these centers do not even have their buildings, nor do they have any

official relationships with blood banks.


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Three Delay Model

There are three delays which negatively contribute to maternal health outcomes, and they

are:

● Delay to seek care

● Delay in transport

● Delay in obtaining care

This further proves that most maternal deaths are easily preventable- it is often, the poor-

quality services which take a mother's life. For instance, an exploration by the UNICEF team at

West Bengal says that the time taken to transport from home to the care facility was around 4-5

hours. However, a woman undergoing postpartum hemorrhage could only survive 2 hours.
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A culture of absence of post and antenatal care also contributes to high number of

maternal deaths. Most health centers were not equipped to deal with women after childbirth, so,

the mothers were sent home soon after. There is no system of following up with the mother.

Many instances of mothers dying on their way to and back from a healthcare facility were

documented. When faced with obstetric emergencies, the time taken to reach a health center via a

designated vehicle also acted as a deterrent when it came to preventing maternal deaths

(Veneman, 2009). Maternal health outcomes in India are unequitable. Kerala, has shown

remarkable progress- the MMR is 61 out of 100,000 live births, with a 100% coverage by

institutional delivery systems. According to Sustainable Development Goals, MMR, along with

the rate of institutional delivery are considered as the two indicators to measure maternal health

(Kumar, 2010). Unsurprisingly, one of the main reasons for poor maternal health outcomes come

from unwanted pregnancies. Abortions contribute to 13% of maternal deaths in India-even

though the medical termination of pregnancy act was passed in 1971, many health centers are not

equipped to deal with them (Kumar, 2010).

Another barrier to tackling maternal deaths is the poor nutritional status of pregnant

woman. A malnutrition crisis among Indian women has not been adequately tackled by

government intervention programs. About 65% of pregnant women in India receive IAF or Iron

and Folic acid tablets, but only 15% of women consume them for the recommended duration

(Kruk, Galea, Prescott & Freedman, 2007).


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There are some other social and cultural factors which have a relationship with the high

MMR in the India. For instance, 27% of the women in Uttar Pradesh get married before the age

of 18. This leads to earlier child births, which are riskier. There are some cultural norms which

are detrimental to women’s health as well. It is a tradition for mothers and their newborns to be

isolated for the first month after child birth in their prenatal homes. This isolation not only

increases chances for postpartum depression, but also negatively affects the woman’s physical

health as she has fewer resources available in isolation (UNDP, 2010).

Preference for sons is also an overarching determinant of maternal death. Especially with

older women, the risk of maternal death increases with a longer obstetric history. Many women

who don’t have sons are forced to move ahead with their fourth or fifth pregnancy to conceive a

male child, despite the family being aware of the risk. Women’s absence of bodily autonomy

combined with lack of decision making and a lesser value being placed on their lives have led to

an acute problem of women dying in motherhood (Veneman, 2009).

Existing Policy Solutions

The most compelling reason necessary to address maternal mortality is that it can be

easily combated. The health systems of various nations can be grouped along their annual GNP as

well as their orientation: as entrepreneurial, welfare-oriented, comprehensive as well as socialistic

(Roemer 1991). Rosenfield and Maine’s influential 1985 work on maternal mortality put maternal

health on the agenda of several international agencies. As a consequence, the Safe Motherhood

Initiative was initiated in 1985, which was a coalition between World Health Organisation (WHO)

, World Bank, United Nations Development Programme (UNDP) , United Nations International

Children's Emergency Fund (UNICEF) , United nations Population Fund (UNFPA), The
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Population Fund as well as International Planned Parenthood Federation (IPPF) . However, in

recent years, the efforts have faded out (Campbell & Graham, 2006).

In general, there is a gap between policy as a resolution and policy as practice. The

earliest attempts from the government, colonial or not, were based on integrating Dai’s into safe

childbirth practice. Evidence for this could be inferences for the establishment of the midwifery

school in Amritsar in 1880,the midwifery act of 1902 and the creation of the Advisory Committee

on Maternal Mortality by the India Council of Medical Research in 1937.However, in the post

independent India, the combination of skilled midwifery and western medicine has been neglected

until a few decades back, starting from the Bhore Committee Report of 1946. According to the

committee recommendations, the government should set up a three tier system which provides:

● Primary care at the village level

● Secondary care at the subdistrict level

● And tertiary care at the regional level

Apex care institutions were also developed, for specialist health care requirements. Along

these lines, India has developed over 144,000 SC , 22,600 Primary Health Centre’s , 4000

Community Health Centre’s, and 242 Apex institutions. However, many Primary and secondary

health centres are not fully equipped- and as a result, they are not fit to deliver solutions for

complicated obstetric problems (Kumar, 2010).

Later, in 1975, the Srivastava committee was established, which recommended linking

the primary health centres to apex institutions. The complex referral system also included an

integrated teaching program for obstetric and paediatrics. However, these suggestions were not

implemented. As a result, most of the practice in maternal health was community based, and
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government appointed Dai’s or Auxiliary nurse midwives ran the sub centre. However, the

policy took a turn for the worse when suggestions based on the Kartar Committee report of 1973

was implemented, when the Multipurpose Worker Scheme was introduced and Auxiliary Nurse

Midwife's responsibility was expanded to include areas outside of maternal health, to primary

health concerns as well as disease control. In addition, the ministry of Maternal and Child health

was renamed to ministry of family welfare. Apart from the obvious semantics, the focus of the

mission was now diluted, and as a result, maternal health efforts deteriorated. In addition to this,

the Indian Nursing council reduced the duration of the ANM turning course from 24 months to 18

months (Mohapatra, 2017).

A decade later, in 1992, the government integrated the Universal Immunisation program

to the Child Survival and Safe Motherhood Program. First Referral Units were set up along with

blood storage units at a sub district level. This policy change was a turn for the better, and as a

result, it improved maternal health outcomes. This program metamorphosed into reproductive and

child health program (RCH), which also covered treatment of sexually transmitted diseases.

The policy improvements under RCH include 24 hour delivery services, funds for referral

transport, training of medical officers. The second face of the program, from 2005 onwards was

placed under the National Rural Health Mission or NRHM. However, RCH is not fully

convergent with NRHM in many states. Under NRHM, Janani Suraksha Yojana a conditional

Cash transfer scheme is one of the key strategies to reduce maternal mortality (Kumar, 2010).

Janani Suraksha Yojana

Janani Suraksha Yojana (JSY), is a central government scheme under the National Rural

Health Mission which replaces the National Maternity Benefit scheme. The objective of this

scheme is to reduce Maternal Mortality Rate ( MMR from now on) and Infant Mortality Ratio
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(IMR from now on) as well as to increase the number of institutional deliveries in Below Poverty

Line (BPL) families. The target of this program is women woman above the age of 19, who

belong to a BPL family. The scheme covers up to two live births. However, for 10 low

performing states, grouped under Empowerment Action Group (EAG), even the third live birth is

covered, if the mother chooses to undergo sterilisation immediately after the delivery. The risk of

maternal mortality increases astronomically for the third pregnancy onwards- therefore, the

women who are in need of institutional deliveries and care workers the most are the ones

undergoing their third pregnancy or more. Hence, it can be argued that this program is not

optimum. Benefits can also be availed by women who are not registered under JSY, given that

they have undergone medical complications during the term of a pregnancy.

One of the key features of JSY is that it divides the target demographic population into

high performing states and low performing states. A Conditional Cash transfer is also to be

availed by the recipients, which is linked by institutional delivery. In addition to this , the

recipients are encouraged, not mandated to take postnatal, antenatal and neonatal check-

ups(Janani Suraksha Yojana, Guidelines for Implementation,2017).The Dai, or the care worker is

also paid some money as part of the scheme. However, this payment is linked to a regimented,

institutional delivery system. The way the scheme is designed, the payment to the care worker is

actually a part of the mother’s package- if the mother chooses not to have a care worker, an

equivalent amount to the care worker is paid to the mother. This could disincentive mothers from

taking the help of the care workers in order to receive funds.

The Auxiliary Nurse Midwife, under this scheme is authorized to administer lifesaving

drugs which are included under antibiotics, oxytocic drugs or IV fluids. A 16 week training

program in obstetric anaesthesia is also encouraged for medical officers, in case of caesarean
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births. In the case of caesarean births, government funds the local CHC or the community health

enter Rs.1500 to hire a private medical practitioner, if a skilled worker is not available at the

CHC. Any complex medical procedures conducted during the term of the pregnancy, like

laparoscopy or tubectomy is covered under the scheme. All payments are made by the ANM or

the Auxiliary Nurse midwife. For this purpose, an imprest money of Rs. 5000 is given to every

ANM. Additionally, Rs 1500 is to be kept with them at all times(Janani Suraksha Yojana,

Guidelines for Implementation,2017).

This program is multifaceted, and has a wide umbrella of positive outcomes, ranging

from rural development to sanitation. The fact that JSY has a heavy reliance on the panchayat raj

system implies that the program is targeted and incisive, and to a large extent, this has worked.

However, a heavy reliance on these institutions means they have to be adequately empowered-

which is not always the case.

Areas of Concern

There have been valiant efforts in post independent India to tackle maternal deaths, but

many of them have been deemed ineffective due to their interaction between social and cultural

factors, unexpected externalities and so on. The most celebrated policy action was the one

recommended by Srivastava committee in 1975 which suggested linking primary health centers

with apex care centers. The integration of child, women’s health and family planning initiatives

under the umbrella of ‘family welfare’ in 1977 was detrimental to the focus of reducing maternal

deaths in India. This led to a decrease in quality of services and created a shortage in the number

of health outreach workers available (Mohammad, 2005).


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The inadequate number of health centers in India raises cause for concern. According to

the Census 2011, around 30 per cent of the state’s population lived in urban areas and 70 per cent

of the state’s population lived in rural areas. However, the state has only one Primary Health

Centre per 28 villages or 44597 people. According to the Rural Health

Statistics 2016, Community Health Centers reported a shortage of 77.6% shortfall of

specialists. In terms of density of nurses, most of the 30 districts with the lowest numbers were in

UP, followed by Bihar and Jharkhand. According to a World Health Organization (WHO) study of

2016, India has some of the lowest share of female health workers of 38 percent, compared with

the world average of 67 percent (Kumar, 2010).

There are several system-induced vulnerabilities indirectly led to maternal health as well.

For instance, Janani Suraksha Yojana (JSY), maternal benefits programme under the National

Rural Health Mission has been criticized for being underwhelming in a state where entitlements

to women are already minimal. A conditional cash transfer of Rs.1400 is awarded to pregnant

women undergoing their first live birth in institutional delivery. However, a recent NFHS survey

showed that the cost of an institutional delivery in the state is Rs.3198, so JSY is not even covering

for half of the out of pocket expenditure (Mohammad, 2005).

Prime Minister Modi’s maternal benefits program has also been criticized on many counts.

The Rs.6000 award under the National Food Security act is not enough compensate for loss of

wage. This policy is also exclusionary in the fact that this money is only available to women who

undergo the first live birth. Only 35% of all the births taking place in Uttar Pradesh are first order

births, thereby excluding a large population of mothers. This also excludes already vulnerable

communities like Scheduled Caste women, who have traditionally had higher fertility rates.

Conditions of full immunization, antenatal care and institutional delivery are exclusionary as well.
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Women who are already excluded from healthcare facilities are further so by excluding Dalit and

Adivasi communities living in poor and remote parts of the country. There is an element of victim

blaming associated with these policies in the sense that conditionalities pertaining to utilizing

health services does not make sense when there is no service guarantee in these parts of the country

(Kumar, 2010).

Policy Alternatives

Iron deficiency anemia is one of the largest contributing factors towards poor maternal

health. Introduction of fortified iron via grains would decrease prevalence of anemia in the country.

Introduction of millets, a grain rich in iron and thiamin into the midday meal programs could

improve long term maternal health outcomes in the country.

The price of a kilogram of millet is three times that of rice. Millets have a weak supply

chain, as opposed to rice and wheat. This creates inefficiencies in many parts of the supply chain

and increases costs, which are then passed on to the customer. Consumer awareness about millets

are also low, because of which greedy intermediaries sell inferior products for higher prices. This

is creating a vicious cycle which makes it unprofitable for the farmer to produce and it and

expensive for the consumer to buy.

However, with increased government support and intervention, these inefficiencies could

be cover come by increased capital investment and promotional campaigns. This would also

encourage farmers to increase production, thus driving down market prices. Introducing millets in

midday meal programs would be more cost effective than fortifying all grains with iron, as is done

in Jharkhand. Akshaya Patra foundation has already piloted the introduction of millets in midday

programs in Karnataka.
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Policy Effectiveness Efficiency Ethical Evaluation Establishing

Option Considerations of recommendations

alternatives

Millets Consumption Millets are Ethically - Millets can be

of Millets is expensive sound introduced in the

not midday meal

widespread. program. They can

also be introduced

alongside rice and

wheat and rice and

subsidized for

female customers

Fortifying Fortification Fortification Mass Food grains can be

wheat/rice of wheat of food medication of fortified at the

increased grains foods raise an public

birthweight could cost ethical distribution system

by 63-70g, anywhere concern. of EAG or

according to between 10 Should the empowerment

a study paisa to Rs. food of every action

conducted by 3. person in the groups, which are

Global per Kg. As country be the

Alliance for of medicated to worst performing


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Improved now, there save the lives states in term of

Nutrition are not cost of few? Even maternal health.

projections if one person

of withdraws

how this consent to

will have them

affect food food fortified,

prices. how will that

affect them

dietary choice

and practices?

Conclusions and Recommendations

The interaction of individual, family, community, health system and structural factors has

a dangerous and sometimes fatal consequence on women. While response to obstetric care

shortages and continuity in care is critical, it is not enough to counter maternal mortality and

morbidity. Maternal health services must be contextualized within the scope of improving

primary health outcomes. This will address other parallel issues like anemia or malaria, which

can have a direct impact on maternal health outcomes. A longer term, sustainable policy

action plan is required to reduce exclusion of highly vulnerable communities like SC’s/ST’s

from accessing health services. Investing in programs that improve their health status, like

increasing access and delivery points and allocating more skilled professional to remote and
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vulnerable areas. Intersectoral coordination is also necessary to evaluate and improve

transportation, nutrition and food safety, safe workplaces as well as violence against women

(Campbell & Graham, 2006). At the very least, this coordination must pervade the program design

level to community level through coordinated services from department of health and education,

Integrated Child Development Services (ICDS) as well as women and child development

institutions (Ruhil, 2015).

References

UNDP. (2010). A Social Determinants Approach to Maternal Health: Roles for Development

Actors. New York. Retrieved from

http://www.undp.org/content/dam/undp/library/Democratic%20Governance/Discussion%20Pape

r%20MaternalHealth.pdf

Veneman, A.M (2009). Maternal and Newborn Health. New York: UNICEF. Retrieved from

https://www.unicef.org/publications/files/SOWC_2009_Main__Report__03112009.pdf

AbouZahr, C. (2003). Safe Motherhood: a brief history of the global movement 1947–2002. British

Medical Bulletin, 67(1), 13-25. doi: 10.1093/bmb/ldg014

Campbell, O., & Graham, W. (2006). Strategies for reducing maternal mortality: getting on with

what works. The Lancet, 368(9543), 1284-1299. doi: 10.1016/s0140-6736(06)69381-1


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Kruk, M., Galea, S., Prescott, M., & Freedman, L. (2007). Health care financing and utilization of

maternal health services in developing countries. Health Policy And Planning, 22(5), 303-310.

doi: 10.1093/heapol/czm027

Kumar, S. (2010). Reducing maternal mortality in India: Policy, equity, and quality issues. Indian

Journal Of Public Health, 54(2), 57. doi: 10.4103/0019-557x.73271

Mohammad, S. (2005). Janani Suraksha Yojana. [New Delhi]: Ministry of Health and Family

Welfare.

Mohapatra, I. (2017). A Study on Utilisation of Janani Suraksha Yojana (JSY) Services in an Urban

Slum in Bhubaneswar, Odisha. Journal Of Medical Science And Clinical Research, 05(01), 15859-

15864. doi: 10.18535/jmscr/v5i1.101

Ruhil, R. (2015). Millennium Development Goals to Sustainable Development Goals.

International Studies, 52(1-4), 118-135. doi: 10.1177/0020881717725926