Prof. V.P. Gupta
Director
Rau’s IAS Study Circle, New Delhi – Jaipur – Bengaluru
In June 2018, Sample Registration System (SRS) bulletin reported that India has registered a significant decline in Maternal Mortality Ratio (MMR) recording a 22% reduction in such deaths since 2013. The MMR stood at 167 in 2011-2013 and has seen a drastic fall in just two years by now standing at 130 in 2014-2016 – a significant improvement on a parameter widely used by analysts and developmental economists to rate a country’s progress.
This is a huge feat for India as the country embarks on an effort to fulfil the goal set out in its National Health Policy, 2017. The National Health Policy has set an MMR target of 100 by 2020, which if achieved will bring in a safe stead to achieve the Sustainable Development Goal of target 3.1 of reducing the MMR to 70 per 100,000 live birth by 2030.
Maternal Mortality Ratio is defined as number of maternal deaths over 100,000 live births. Further maternal death as defined by WHO is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age especially in developing countries. Hence, the maternal mortality ratio represents the risk associated with each pregnancy.
The data released by the Sample Registration System (SRS) reveals that India has gone beyond the Millennium Development Goal target of reducing Maternal Mortality Ratio (MMR) to 39 by 2015. Further three states in
India – Kerala, Maharashtra and Tamil Nadu—have already met the SDG target for MMR of 70 per 1,00,000 and India’s MMR is lower than the global average of 216 (2015 data).
Still a long way to go
Despite all these facts and figures, India still has a long way to go. A maternal death is the outcome of a chain of events and disadvantages throughout a woman’s life—poor nutrition during childhood, early marriages, lack of institutional healthcare during and post pregnancy are just few of the causes for maternal deaths.
The major reason for India’s improvement is still the major reason why maternal deaths remain high in India—Institutional healthcare and deliveries or the lack of it.
Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. But such complications go unaddressed because women don’t have access to the required healthcare services—poverty, remoteness of healthcare centres, lack of quality health workers, lack of antenatal services, lack of awareness are some of the reasons for the same.
All these reasons translate into women not being able to have an institutional/hospital delivery. This means that lakhs of births are not assisted by a midwife, a doctor or a trained nurse and are conducted at home without any medical supervision.
Secondly, unsafe abortions are another leading cause of maternal deaths in India. Research by The Lancet, January 2018 shows that half the pregnancies in India are unintended and that a third result in abortion. Only 22% of abortions are done through public or private health facilities. Lack of access to safe abortion clinics, particularly public hospitals, and stigma and attitudes toward women, especially young, unmarried women seeking abortion, contribute to this. Doctors refuse to perform abortions on young women or demand that they get consent from their parents or spouses despite no such requirement by law. This forces many women to turn to clandestine and often unsafe abortions. Further, the Medical Termination of Pregnancy (MTP) Act, 1971 provides for termination only up to 20 weeks. If an unwanted pregnancy has proceeded beyond 20 weeks, women have to approach a medical board and courts to seek permission for termination, which is extremely difficult. The MTP Act is long overdue for a comprehensive reform.
In addition to this, various social factors contribute to maternal deaths. The prominent grey areas in our society are the age at marriage and child bearing, child spacing, family size and fertility patterns, literacy, socio-economic status and also not to forget the customs and beliefs. All this adds to the problems of women especially the adolescent girls who are at a larger risk.
International perspective
The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia. More than half of maternal deaths occur in fragile and humanitarian settings.
The Maternal Mortality Ratio in developing countries in 2015 is 239 per 100,000 live births versus 12 per 100,000 live births in developed countries. There are large disparities between countries, but also within countries, and between women with high and low income and those women living in rural versus urban areas. Women in developing countries have, on average, many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of maternal death—the probability that a 15-year old woman will eventually die from a maternal cause—is 1 in 4900 in developed countries, versus 1 in 180 in developing countries.
Steps by Indian government
India’s success in reducing MMR has been attributed to the government’s effort
Ø The Janani Suraksha Yojana (JSY) is a centrally sponsored Scheme which is being implemented with the objective of reducing maternal and infant mortality by promoting institutional delivery among pregnant women. Under the JSY, eligible pregnant women are entitled for cash assistance irrespective of the age of mother and number of children for giving birth in a government or accredited private health facility.
Ø Another major scheme is the Pradhan Mantri Matru Vandana Yojana. PMMVY is a Maternity Benefit Programme that is implemented in all the districts of the country in accordance with the provision of the National Food Security Act, 2013 and it aims to provide partial compensation for the wage loss in terms of cash incentive so that the woman can take adequate rest before and after delivery of the first living child. The cash incentive provided would lead to improved health seeking behaviour amongst the Pregnant Women and Lactating Mothers.
Ø Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) is a fixed day strategy, every month across the country during which a range of quality maternal health services are envisaged to be provided as part of Antenatal Care. Under the campaign, a minimum package of antenatal care services is to be provided to the beneficiaries on the 9th day of every month at the Pradhan Mantri Surakshit Matritva Clinics to ensure that every pregnant woman receives at least one check-up in the 2nd/ 3rd trimester of pregnancy.
Ø Additionally under the Ayushman Bharat Abhiyaan, more than 1.5 lakh wellness centres have been planned to provide comprehensive health care (this includes non-communicable diseases, maternal and child health services, free essential drugs and diagnostic services).
Ø Other major initiatives under the umbrella of National Health Mission (NHM) like augmentation of infrastructure and human resource, capacity building have led to an improvement. Janani Shishu Suraksha Karyakaram which provides for free transport, deliveries and care for pregnant women at public health institutions, and have also contributed to the success.
In addition to this, the facilities in public hospitals and health centres have also improved and government is providing free drugs and diagnostics among other incentives to pregnant women and that has led to increase in admissions for delivery over the years.
Apart from the increase in institutional deliveries, other factors include involving private doctors to provide free health check-ups to pregnant women at government hospitals, decline in child marriages, a reduction in teenage pregnancies by 50%, and more women being treated for anaemia.
Way forward
Sexual and reproductive rights in India must include a concern with maternal deaths, access to maternal care to safe abortions, access to contraceptives, adolescent sexuality, prohibition of forced medical procedures such as forced sterilisations and removal of stigma and discrimination against women, girls and LGBTI persons on the basis of their gender, sexuality and access to treatment.
Access to healthcare in terms of maternal health should be given to all women. This encompasses a broad spectrum of interventions ranging from educating and empowering women with regard to maternal health; family planning initiatives; addressing inequities in access to and quality of sexual, reproductive, and maternal healthcare; widening the parochial minded stigma against unmarried pregnant women; enhanced mobilisation of individuals and communities; and increased government funding for improving infrastructure and training staff to tackle major causes of maternal deaths across all delivery points. Each and every kind of barriers—be it social, economic or institutional—that limits access to quality maternal health services must be identified and addressed at all levels of the health system