As per the Sample Registration System bulletin released last month, India has registered a 77 per cent decline in the Maternal Mortality Ratio (MMR) from 556 per 100,000 live births in 1990 to 130 per 100,000 live births in 2016.
It is even more heartening that socio-economically backward areas referred to as the Empowered Action Group (EAG) States have registered the maximum decline in MMR.
Several initiatives in health and nutrition have made this possible. The Janani Suraksha Yojana (JSY) launched in 2005 contributed to a surge in institutional deliveries from 38.7 per cent in 2005-06 to 78.9 per cent in 2015-16 by integrating cash incentives with delivery and post-delivery care. Other initiatives include the Pradhan Mantri Surakshit Matritva Abhiyan launched in 2016 for engaging the private sector to voluntarily provide free antenatal services on the 9th day of every month to pregnant women as well as the Pradhan Mantri Matru Vandana Yojana under which a cash incentive of ₹5,000 is provided to encourage antenatal check-ups for pregnant women and lactating mothers.
While interventions that directly impact health and nutrition have an important role to play in reducing maternal mortality, improvements in key economic and social factors are also major contributors. For instance, though slow, female literacy increased from 55.1 per cent in 2005-06 to 68.4 per cent in 2015-16. Similarly, according to UNICEF, India saw a sharp decline in child marriages over the last 10 years with 27 per cent of girls getting married before their 18th birthday as against 47 per cent a decade ago.
Research indicates that the growth in per capita Net State Domestic Product and reduction in the poverty ratio have a statistically significant association with the decline of MMR in India. A better socio-economic status enables couples to limit their family size through the effective use of contraceptives.
While the progress has undoubtedly been impressive, in order to achieve the Sustainable Development Goal of reducing MMR to 70 by 2030 or earlier, systematic efforts need to be made to eliminate disparities in maternal health outcomes across the country, adopt a comprehensive and coordinated policy approach as well as ensure a relentless focus on monitoring the implementation of safe birthing guidelines.
Maternal mortality varies significantly within and between States. Kerala’s MMR, for instance, was 46 in 2016 compared to Assam’s 237. In order to address these disparities, it is imperative that data pertaining to the different causes of maternal deaths is analysed at regular intervals and policy actions are prioritised accordingly. This requires strengthening of surveillance and monitoring systems such as the Mother and Child Tracking System and the Health Management Information System as well as the promotion of vital registration.
Currently, haemorrhage is the leading cause of maternal mortality in the country followed by sepsis and abortion. This points to the need for urgently exploring the possibility of a national blood transfusion service network considering that India has a blood supply deficit of 25 per cent as against the prescribed reserve of 1 per cent of the population, according to the World Health Organisation.
While the relative shares of the causes of maternal deaths are similar across regions, hypertensive disorders are a more important cause in south India and abortion-related deaths are higher in the EAG States and Assam, thereby necessitating the design of customised policy interventions.
Eliminating regional disparities also requires that health and nutrition services are accessible to the most vulnerable groups. For instance, according to the National Family Health Survey (NFHS)-4, despite improvements, only 58.6 per cent of mothers had received an antenatal check-up in the first trimester and 51.2 per cent of mothers had undergone at least four antenatal care visits.
Lessons should be drawn from States that have been successful in improving the MMR, especially among vulnerable groups. Telangana, for instance, had a high MMR among women in tribal areas due to limited access to medical services.
In response to this, the State government implemented a 24-hour call centre in conjunction with its Amma Vodi programme which provides financial incentives for institutional deliveries. The call centres help to track pregnant women and ensure that they receive antenatal check-ups on time.
While institutional deliveries play an important role in reducing maternal mortality, it is crucial to maintain an equally strong focus on other policy interventions that impact maternal health. For instance, NFHS-4 estimates that one out of every two pregnant women is anaemic. The POSHAN Abhiyaan launched earlier this year therefore has a vital role to play in improving the nutritional status of women.
To accomplish this, a comprehensive package of services delivered by multiple ministries will need to be brought under the POSHAN Abhiyaan umbrella to foster convergence among programmes focused on the pre-pregnancy (reducing child marriages, birth spacing), pregnancy (antenatal checks, nutrition counselling) and post-pregnancy (institutional deliveries, post-natal care) phases.
Similarly, investments in girls’ education need to be stepped up. Evidence suggests that girls who attain a basic education level are more likely to exert greater influence in limiting the size of their families in adulthood. Focusing on women’s education and empowerment through the self-help group movement has helped States such as Bihar to achieve a sharp fall in MMR.
Training and monitoring
The shortage of trained human resources, especially doctors and auxiliary nurse midwives, remains a key challenge to improving maternal health outcomes. Human resource compensation packages for personnel working in remote and rural areas need to be made more attractive. Additionally, the focus in gynaecology training needs to be on imparting practical skills in the management of labour and deliveries.
The Union Health Ministry has launched LaQshya (Labour Room Quality Improvement Initiative), a safe delivery mobile application for health workers who manage deliveries in peripheral areas as well as the Operational Guidelines for Obstetric High Dependency Units and Intensive Care Units. The implementation of these guidelines needs to be monitored rigorously and refresher training sessions conducted for health workers whenever necessary.
Although India has performed far better than the global average as far as reducing maternal deaths between 1990 and 2016 is concerned, we have a fair bit of catching up to do with major economies like Brazil (44), China (27) and Japan (5). Ultimately though even one maternal death is too many and concerted efforts need to be made by all stakeholders to ensure that no woman loses her life to a preventable cause.
Prasad is Public Policy Specialist, Office of Vice-Chairman, NITI Aayog, and Shekhar is Young Professional. The views expressed are personal.