Maternal mortality ratio is falling but more effort required to catch up with China
The country's maternal mortality ratio (MMRatio) exceeds that of China by a huge margin, which not only indicates the poor status of women in our society but also the miserable functioning of health system, among other things. However, there is some good news around the corner to cheer about.
Recently released data by the Sample Registration System (SRS) bulletin indicates that for the country as a whole the MMRatio has declined steadily from 398 in 1997-98 to 130 in 2014-16, which is a fall by 67.3 percent. During 2014-16, the lowest MMRatio was found in Kerala (46.0), followed by Maharashtra (61.0) and Tamil Nadu (66.0). On the contrary, Assam (237.0) has the highest MMRatio, followed by Uttar Pradesh/ Uttaranchal (201.0) and Rajasthan (199.0).
Although the country's MMRatio has reduced by 22.2 percent between 2011-13 and 2014-16, it went down by 6.2 percent between 2010-12 and 2011-13. Please consult the interactive chart-1.
Kerala (69.3 percent) witnessed the biggest decline in MMRatio since 1997-98, followed by Bihar/ Jharkhand (68.9 percent) and Uttar Pradesh/ Uttaranchal (66.8 percent). However, the state, which faced the highest fall in MMRatio between 2011-13 and 2014-16, is Uttar Pradesh/ Uttaranchal (29.5 percent), followed by Kerala (25.1 percent).
Experts say that the state's better health infrastructure, improvement in delivery care facilities (including hospital deliveries) and betterment of nutritional level among pregnant women may have contributed towards Kerala's low MMRatio over the years vis-à-vis other states.
According to the SRS, the MMRatio refers to the number of women who die as a result of complications of pregnancy or childbearing in a given year per 100,000 live births in that year. From the interactive chart-1, it could be observed that almost for all the years, altogether the southern states (viz. Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) have exhibited a lower MMRatio vis-à-vis the 8 Empowered Action Group (EAG) states (viz. Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Odisha and Rajasthan) and also Assam.
It could be further noticed that from 1999-2001 onwards among the sub-group totals, the MMRatio was the highest for ‘EAG and Assam sub-total’, followed by ‘Other sub-total’ (comprising the states of Gujarat, Haryana, Maharashtra, Punjab, West Bengal and others) and 'South sub-total'.
A press release by the Ministry of Health and Family Welfare dated 6th June, 2018 says that initiatives like the Mission Indradhanush and Intensified Mission Indradhanush in the low performing states have helped in reducing MMRatio. Other initiatives under the umbrella of National Health Mission (NHM) like augmentation of infrastructure and Human Resources, Capacity-Building and Janani Shishu Suraksha Karyakaram (JSSK), which provides for free transport and care for pregnant women may have also helped in trimming MMRatio.
The recent bulletin says that verbal autopsy instruments are administered for the deaths reported under the SRS on a regular basis so as to yield cause-specific mortality profile in the country. Readers may note that the SRS is the largest demographic sample survey in the country, which is conducted by the Office of the Registrar General, India of the Ministry of Home Affairs.
The website of MeasureEvaluation (https://bit.ly/2t3f8kF) -- a partnership involving more than 5 organisations including the US Agency for International Development (USAID) -- says that it is difficult to investigate maternal deaths because of the comparative rarity of such deaths on a population basis, apart from other context-specific factors, such as reluctance to report abortion-related deaths, problems of memory recall, or lack of medical attribution. If there is a significantly large population of non-users of health services, then it would not be prudent to rely heavily on health services data on MMRatio. Inaccuracies in routine registers and omission of deaths occurring outside maternity wards may also add to the problems related to using such health services information extensively.
Instead of a precise measure, MMRatios broadly indicate the level of maternal mortality because of the limitations inherent in most measurement methods. In order to know more about MMRatio, please go to https://bit.ly/2t3f8kF
International comparisons on MMRatio
As could be seen from the chart-2, although the yawning gap between India and China in terms of MMRatio has reduced significantly between 2000 and 2017, the former has to put more efforts in order to catch up with the latter. The absolute difference in MMRatio between India and China has lessened from 311 in 2000 to 116 in 2017. The country's MMRatio was 6.3 times that of China in 2000, which has reduced to 5 times in 2017.
Chart 2: Trends in Maternal Mortality Ratio (modeled estimate, per 100,000 live births), 2000 to 2017
Source: WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization, 2019
Note: Maternal mortality ratio is the number of women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births. The data are estimated with a regression model using information on the proportion of maternal deaths among non-AIDS deaths in women ages 15-49, fertility, birth attendants, and GDP.
It could be observed from the Chart-2 that the absolute gap in MMRatio between Bangladesh and India has reduced from 64 in 2000 to 28 in 2017.
How is MMRatio different from MMR?
According to the SRS, maternal mortality rate (MMR) is defined as the number of maternal deaths to women in the ages 15-49 per lakh of women in that age group.
From the interactive chart-3, it could be noticed that the country's MMR as a whole has fallen from 11.7 in 2011-13 to 8.8 in 2014-16, which is a reduction by 24.8 percent.
Kerala (2.1) has the lowest MMR in 2014-16, followed by Andhra Pradesh (3.6) and Maharashtra (3.7). As opposed to that, Rajasthan (18.3) has the highest MMR, followed by Uttar Pradesh/ Uttaranchal (17.1) and Assam (16.2).
The state, which faced the highest decline in MMR between 2011-13 and 2014-16, is Andhra Pradesh (39.0 percent), followed by Uttar Pradesh/ Uttaranchal (38.0 percent) and Kerala (34.4 percent). In Karnataka (12.0 percent) and Tamil Nadu (15.6 percent), there was a rise in MMR between 2011-13 and 2014-16.
Among the sub-group totals, MMR was the highest for ‘EAG and Assam sub-total’ (comprising Assam, Bihar/ Jharkhand, Madhya Pradesh/ Chhattisgarh, Odisha, Rajasthan and Uttar Pradesh/ Uttaranchal) in both 2011-13 and 2014-16, followed by ‘Other sub-total’ (comprising Gujarat, Haryana, Maharashtra, Punjab, West Bengal and others) and 'South sub-total' (comprising Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu).
The website of MeasureEvaluation (https://bit.ly/2t3f8kF) explains that the MMRatio measures obstetric risk (i.e., the risk of dying once a woman is pregnant). However, MMRatio excludes the risk of being pregnant (i.e., fertility, in a population, which is measured by the MMR or the lifetime risk).
Special Bulletin on Maternal Mortality in India 2014-16, dated May, 2018, Sample Registration System, Office of the Registrar General, India, please click here to access
Special Bulletin on Maternal Mortality in India 2011-13, Sample Registration System, Office of the Registrar General, India, please click here to access
Compendium of India's Fertility and Mortality Indicators, 1971-2013, Sample Registration System, Office of the Registrar General, India, please click here to access
Sample Registration System, Office of the Registrar General & Census Commissioner, India, please click here to access
A Presentation on Maternal Mortality Levels (2010-12), dated 20 January, 2013, please click here to access
Maternal Mortality Ratio (MMR), Family Planning and Reproductive Health Indicators Database, MeasureEvaluation, please click here to access
India shows impressive gains in reduction of Maternal Mortality with 22% reduction since 2013, Press Information Bureau, Ministry of Health and Family Welfare, dated 6 June, 2018, please click here to access
Shri JP Nadda highlights the achievements of the Health Ministry, Press Information Bureau, Ministry of Health and Family Welfare, dated 11 June 2018 please click here to access
Maternal mortality ratio in the country drops to 130 from 167 -Ramya Kannan, The Hindu, 6 June, 2018, please click here to access
India registers 22% reduction in maternal mortality ratio since 2013: report -Neetu Chandra Sharma, Livemint.com, 7 June, 2018, please click here to access
India Records 22% Drop in Maternal Mortality Rate, TheWire.in, 7 June, 2018, please click here to read more
Kerala's maternal mortality rate drops to 46, govt aims 30 by 2020 -Vishnu Varma, The Indian Express, 7 June, 2018, please click here to access
Image: UNDP India