The rest of India must learn from the southern states to reduce maternal deaths for attaining SDG-3 target
The newly released Special Bulletin on Maternal Mortality in India 2016-18 shows that India's maternal mortality ratio (MMRatio) has reduced from 130 maternal deaths per one lakh live births during 2014-16 to 122 during 2015-17, and it further dropped to 113 during 2016-18.
According to the Sample Registration System (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. This ratio shows the risk of maternal death with respect to the number of live births.
Although the country has performed well in reducing the MMRatio over the years, it has to make sustained efforts in the forthcoming years to bring down its MMRatio to below 70 maternal deaths per lakh live births by the year 2030 in order to achieve one of the Sustainable Development Goals (SDGs) of the United Nations i.e. achieve target 3.1.1 under SDG-3, which is about ensuring healthy lives and promoting well-being for all at all ages.
Maternal Mortality Ratio
A high MMRatio indicates the low status that women experience in a society besides miserable functioning of health services delivery system and low nutritional status of pregnant women.
Published by the Sample Registration System (SRS) of the Office of the Registrar General (India), the latest bulletin shows that as compared to the national level MMRatio of 113 during 2016-18, states like Assam (215), Bihar (149), Madhya Pradesh (173), Chhattisgarh (159), Odisha (150), Rajasthan (164), Uttar Pradesh (197) and Punjab (129) have performed badly. Most of the underperforming states (except Punjab) are Empowered Action Group (EAG) states. Please check details in table-1.
Table 1: Maternal Mortality Ratio (MMR), Maternal Mortality Rate and Life Time Risk; India, EAG & Assam, South and Other states, 2016-18
The states that have performed better than the national level MMRatio of 113 are Jharkhand (71), Uttarakhand (99), Andhra Pradesh (65), Telangana (63), Karnataka (92), Kerala (43), Tamil Nadu (60), Gujarat (75), Haryana (91), Maharashtra (46), West Bengal (98) and other states (85).
Kerala (43) has the lowest MMRatio vis-à-vis other states/ UTs thanks to its comparatively better health infrastructure, improved delivery care facilities (including hospital deliveries) and better nutritional status of pregnant women. Most southern states (except Karnataka) have already achieved the SDG-3 target pertaining to MMRatio. Assam has the highest (215) MMRatio as compared to other states/ UTs.
In the recent SRS bulletin on maternal mortality, states have been categorized into three groups, namely “Empowered Action Group” (EAG) states comprising Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand and Assam; “Southern” states which include Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu; and “Other” states covering the remaining states/ UTs.
In order to know the past trends of the states/ UTs, please click here to read the news alert entitled 'The country has miles to go in reducing maternal deaths', dated 20th November, 2019.
Verbal Autopsy (VA) instruments are administered for the deaths reported under the SRS on a regular basis to yield cause-specific mortality profile in the country, says the bulletin. As per the World Health Organization (WHO), maternal death 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.
International Comparison on MMRatio
According to the State of World Population 2020 report entitled Against My Will - Defying the practices that harm women and girls and undermine equality (released in June 2020) that has been published by the United Nations Population Fund (UNFPA), in South Asia, the MMRatio was the highest in Afghanistan (638), followed by Myanmar (250), Nepal (186), Bhutan (183), Bangladesh (173), India (145), Pakistan (140), Maldives (53), Sri Lanka (36) and China (29) in 2017.
The report entitled Trends in Maternal Mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division had found that Nigeria and India faced 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 indicated that MMRatio for the country (modelled estimate) was 370 in 2000, 286 in 2005, 210 in 2010, 158 in 2015 and 145 in 2017.
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. This rate indicates the risk of maternal death per pregnancy or per birth and the level of fertility in a population. Please click here in order to understand the relationship between MMR and MMRatio.
As compared to the national-level MMR of 7.3 during 2016-18, states like Assam (14.0), Bihar (15.1), Madhya Pradesh (15.9), Chhattisgarh (12.1), Odisha (9.7), Rajasthan (14.5) and Uttar Pradesh (17.8) have performed poorly. Please consult table-1 for details.
The states that have performed better than the national level MMR of 7.3 during 2016-18 are Jharkhand (5.6), Uttarakhand (6.4), Andhra Pradesh (3.6), Telangana (3.6), Karnataka (4.9), Kerala (2.1), Tamil Nadu (3.2), Gujarat (5.1), Haryana (7.0), Maharashtra (2.6), Punjab (7.0), West Bengal (5.0) and other states (4.5).
Kerala (2.1) has the lowest and Uttar Pradesh (17.8) has the highest MMR vis-à-vis other states/ UTs.
According to the SRS, lifetime risk is defined as the probability that at least one woman of reproductive age (15-49 years) will die due to child birth or puerperium assuming that chance of death is uniformly distributed across the entire reproductive span.
Against the lifetime risk of 0.3 percent prevailing at the national level during 2016-18, states like Assam (0.5 percent), Bihar (0.5 percent), Madhya Pradesh (0.6 percent), Chhattisgarh (0.4 percent), Rajasthan (0.5 percent) and Uttar Pradesh (0.6 percent) have performed relatively poorer. Please see table-1 for details.
As opposed to that, states that have performed better than or same as the national level lifetime risk of 0.3 percent are Jharkhand (0.2 percent), Odisha (0.3 percent), Uttarakhand (0.2 percent), Andhra Pradesh (0.1 percent), Telangana (0.1 percent), Karnataka (0.2 percent), Kerala (0.1 percent), Tamil Nadu (0.1 percent), Gujarat (0.2 percent), Haryana (0.2 percent), Maharashtra (0.1 percent), Punjab (0.2 percent), West Bengal (0.2 percent) and other states (0.2 percent).
The highest lifetime risk among states/ UTs has been found in Uttar Pradesh and Madhya Pradesh (0.6 percent each). The lowest lifetime risk among states/ UTs has been observed in Andhra Pradesh, Telangana, Kerala, Tamil Nadu and Maharashtra (0.1 percent each).
During 2016-18, most maternal deaths have occurred among women in the age group 20-24 years (33 percent), followed by 25-29 years (32 percent), 30-34 years (17 percent), 35-39 years (7.0 percent), 15-19 years (5.0 percent), 40-44 years (4.0 percent) and 45-49 years (1.0 percent).
Sustainable Development Goals National Indicator Framework Progress Report, 2020 (Version 2.1), National Statistical Office (NSO), Ministry of Statistics and Programme Implementation (MoSPI), please click here to access
State of World Population 2020 report entitled Against My Will - Defying the practices that harm women and girls and undermine equality (released in June 2020), published by the United Nations Population Fund, please click here and 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, here and here to access
National Health Policy 2017, Ministry of Health and Family Welfare, please click here to access
A Presentation on Maternal Mortality Levels (2010-12), Office of the Registrar General (India), please click here to access
News alert: The country has miles to go in reducing maternal deaths, Published on Nov 20, 2019, Inclusive Media for Change, please click here to read more
Ensuring delayed marriage requires concerted efforts to keep girls in school for longer -Sheila Vir, The Indian Express, 28 July, 2020, 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
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: Inclusive Media for Change/ Shambhu Ghatak