The country has miles to go in reducing maternal deaths

The country has miles to go in reducing maternal deaths

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published Published on Nov 20, 2019   modified Modified on Aug 5, 2020

 

A high maternal mortality ratio (MMRatio) indicates low status of women in the society apart from poor functioning of health services delivery system. Recently released data by the Sample Registration System (SRS) bulletin indicates that for the country as a whole the MMRatio has steadily declined from 398.0 in 1997-98 to 122.0 in 2015-17, which is a fall by -69.3 percent.

Table-1 shows that India's MMRatio was 398.0 in 1997-98, 327.0 in 1999-01, 301.0 in 2001-03, 254.0 in 2004-06, 212.0 in 2007-09, 178.0 in 2010-12, 167.0 in 2011-13, 130.0 in 2014-16 and 122.0 in 2015-17. The United Nations' Sustainable Development Goals (SDGs), however, require the country to bring down its MMRatio to 70 maternal deaths per lakh live births by the year 2030.

During 2015-17, the lowest MMRatio was found in Kerala (42.0), followed by Maharashtra (55.0) and Tamil Nadu (63.0). Assam (229.0) had the highest MMRatio, followed by Uttar Pradesh (216.0) and Madhya Pradesh (188.0).

Although India's MMRatio has declined by -6.2 percent between 2014-16 and 2015-17, it went down by -22.2 percent between 2011-13 and 2014-16 (viz. a fall by -7.4 percent a year on average). Please consult table-1.

It may be noted that since 1997-98 the government was clubbing together the MMRatio data for Bihar and Jharkhand as well as Madhya Pradesh and Chhattisgarh. It was even combining the data for Uttar Pradesh and Uttaranchal/ Uttarakhand. However, the MMRatio data for these states has been provided on individual basis in 2015-17. Therefore, it is not possible to compare the current version of the data with previous years and present the trends in MMRatio for these states.

Table-1 indicates that Kerala witnessed a fall in MMRatio by -72.0 percent between 1997-98 and 2015-17. Experts think 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.
 
MMRatio for West Bengal came down from 303.0 to 94.0 between 1997-98 and 2015-17 viz. a fall by -69.0 percent. Kindly see table-1.

Table 1: Maternal Mortality Ratio, India and Bigger States, 1997-1998 to 2015-17

Table 1 Maternal Mortality Ratio, India and Bigger State 1997-1998 to 2015-17
Source: Sample Registration System, Office of the Registrar General & Census Commissioner, India, please click here to access 
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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 table-1, it is observed that almost for all the years, altogether the southern states (viz. Andhra Pradesh, Telangana, 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, Orissa and Rajasthan) and also Assam.

The decline in MMRatio has been most significant in EAG states and Assam from 188 to 175 between 2014-16 and 2015-17 (viz. by -6.9 percent). Among the southern states, the fall between these two time points has been from 77 to 72 (viz. by -6.5 percent) and in the 'Other sub-total' from 93 to 90 (viz. by -3.2 percent).

It could be further seen that from 1999-2001 onwards among the group sub-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 other states) and 'South sub-total'.

An international report entitled Trends in Maternal Mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, published recently, finds that Nigeria and India had the highest estimated numbers of maternal deaths, accounting for approximately one-third (35 percent) of estimated global maternal deaths in 2017, with approximately 67,000 and 35,000 maternal deaths (23 percent and 12 percent of global maternal deaths), respectively. That report also shows that MMRatio for the country (modelled estimate) was 370 in 2000, 286 in 2005, 210 in 2010, 158 in 2015 and 145 in 2017.

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.

A press release by the Ministry of Health and Family Welfare dated 6th June, 2018 says that initiatives like 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 reducing MMRatio.

The recently released bulletin says that verbal autopsy instruments are administered for the deaths reported under the SRS on a regular basis to yield cause-specific mortality profile in the country.

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.

Maternal Mortality Rate

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 table-2, it is observed that India's MMR as a whole has fallen from 11.7 in 2011-13 to 8.8 in 2014-16, and further to 8.1 in 2015-17.

Table 2: Maternal Mortality Rate, India and Bigger States, 2011-13 to 2015-17

Table 2 Maternal Mortality Rate India and Bigger States 2011-13 to 2015-17

Source: Sample Registration System, Office of the Registrar General & Census Commissioner, India, please click here to access 
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Kerala (1.9) had the lowest MMR in 2015-17, followed by Maharashtra (3.3) and Andhra Pradesh (3.6). Uttar Pradesh (20.1) had the highest MMR in 2015-17, followed by Madhya Pradesh (17.5) and Bihar (16.9).

It is impossible to compare the current version of the data with previous years and present the trends in MMR for the  states of Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh and Uttaranchal/ Uttarakhand. Please check table-2.

The decline in MMR has been most significant in southern states from 4.7 to 4.2 between 2014-16 and 2015-17 (viz. by -10.6 percent). Among the EAG states and Assam, the fall between these two points has been from 16.0 to 14.6 (viz. by -8.8 percent) and in the 'Other sub-total' from 5.4 to 5.1 (viz. by -5.6 percent).

Among the sub-group totals, MMR was the highest for ‘EAG and Assam sub-total’ (comprising Assam, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and Uttaranchal/ Uttarakhand) in 2011-13, 2014-16 and 2015-17, followed by ‘Other sub-total’ (comprising Gujarat, Haryana, Maharashtra, Punjab, West Bengal and other states) and 'South sub-total' (comprising Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu).

How is Maternal Mortality Ratio different from Maternal Mortality Rate?

Often researchers and media persons are found to use the terms maternal mortality ratio (MMRatio) and maternal mortality rate (MMR) interchangeably to mean the number of maternal deaths per 100,000 live births. However, as per the World Health Organization (WHO), the two are different concepts. MMRatio viz. the number of maternal deaths per 100,000 live births, is a measure of the risk of death once a woman has become pregnant. In order to understand the concept of MMRatio, please consider this example. There is a village that has 1,000 people. Twenty women in that village become pregnant. There is miscarriage of 5 babies. Fifteen women give birth to 15 live babies. Five women who gave birth die due to complications in the pregnancy. In this case the MMRatio is 5 maternal deaths out of 15 live births, which is 33.3 percent.

As opposed to MMRatio, MMR is the number of maternal deaths (direct and indirect) in a given period per 100,000 women of reproductive age (15-49 years) during the same time period. In order to understand the concept of MMR, kindly consider this example. There is a village that has 1,000 people. There are 500 women, out of which 400 women belong to the reproductive age. Last year, 15 women gave birth to fifteen live babies. Five women died due to complications in the pregnancy. The MMR, therefore, is 5 maternal deaths out of 400 women of reproductive age, which is 1.25 percent.


References


Special Bulletin on Maternal Mortality in India 2015-17, released in November, 2019, Sample Registration System, Office of the Registrar General, India, please click here to access

Trends in Maternal Mortality 2000 to 2017: Estimates by WHO, UNICEF, World Bank Groups and the United Nations Population Division, released in September 2019, World Halth Orgnization (WHO), United Nations Children's Fund (UNICEF), World Bank Groups, United Nations Population Fund (UNFPA) and the United Nations Population Division, please click here to access 

Special Bulletin on Maternal Mortality in India 2014-16, released in 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 and 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), please click here to access

Maternal mortality ratio (MMR), Family Planning and Reproductive Health Indicators Database, 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 

 
Monitoring Health in the Sustainable Development Goals: 2017, World Health Organization, Regional Office for South East Asia, as quoted in the National Health Profile 2018, page no. 288, please click here to access 

Maternal mortality ratio is falling but more effort required to catch up with China, News alert by Inclusive Media for Change dated 12 June, 2018, please click here to access 

The drop in the maternal mortality ratio is just the first step, The Telegraph, 18 November, 2019, please click here to access

Explained -- Maternal mortality rate in the states: Assam 229, Kerala 42, The Indian Express, 9 November, 2019, please click here to access 

India losing fewer mothers to childbirth, data reveal, The Hindu Business Line, 8 November, 2019, please click here to access 

Maternal death rate declining: report -Afshan Yasmeen, The Hindu, 8 November, 2019, please click here to access

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 Courtesy: UNDP India


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