How big is the problem of maternal deaths in India? What are the factors associated with the maternal deaths in India?
India faces a problem of high maternal mortality. According to the estimation done by The World Health Organisation (WHO), United Nations Children’s Fund (UNICEF), United Nations Fund for Population Activities (UNFPA)India had the maternal mortality ratio of 230 (150–350) /100,000 live births in 2008 with 63000 maternal deaths in the same year, which is the largest in the world(WHO 2010, Trends in maternal mortality 1990–2008).
According to the estimates of the Registrar General of India (RGI), Ministry of Home Affairs the maternal mortality ratio in India has dropped from 301/100,000 live births (2001–2003) to 212/100,000 live births(2007–2009) .The Maternal mortality ratio differs from state to state.
“Determinants of maternal mortality in India are medical causes and social factors. A large number of social factors influencing maternal mortality like age of the mother, age of marriage, parity, birth spacing, family size, malnutrition, poverty, illiteracy”.(Joshi and Kushwah.2011.An epidemiological study of social factors associated with maternal mortality in the community development block of Madhya Pradesh.)
LITERATURE REVIEW
WHO, 2010 defines Maternal Death as the “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”.Maternal mortality ratiodescribes the risk of maternal death relative to the number of live births.
WHO estimates that 536,000 maternal deaths globally each year and 136000 of these maternal deaths occur in India. The total fertility rate stands at 2.9 which indicated to an increased lifetime risk of maternal deaths. Reduction in the number of maternal deaths has been a matter of concern for India.
However getting reliable data in this aspect is difficult due to large population size, geographic vastness, sociocultural diversity, lack of infrastructure. Therefore one has to rely on the data available by the International Organizations or by the ministry of health.
The current MMR of India is 212 maternal deaths per 100,000 live births (Live births, maternal deaths, maternalmortality ratio in India by state from 2001–2003, 2004–2006, 2007–2009 special survey of death. Source: RGI 2009 -10)
However, according to the WHO,2010 report it is 230 maternal deaths per 100,000 live births. At country level it has declined from 301 maternal deaths per 100,000 live births in 2004 to 254 in 2006 to 212 in 2009. (Live births, maternal deaths, maternal mortality ratio in India by state from 2001–2003, 2004–2006, 2007–2009 special survey of death.Source: RGI 2009–2010).
The MMR is unevenly distributed at state level. The MMR has reduced as compared to 2004–2006. Assam has the highest MMR in the country with 390 maternal deaths per 100,000 live births it has reduced from 480 in 2004. Uttar Pradesh had 440 maternal deaths per 100,000 live births in 2004 and now it has reduced to 359. Bihar/Jharkhand reported MMR of 312 in 2004, it has declined to 261 now. Madhya Pradesh had a MMR of 335 in 2004it has now declined to 269. Maharashtra had a MMR of 130 in 2004 and in 2009 it reported to have a MMR of 104. Gujarat had a MMR of 160 and it has been reduced to 148 now.
However, there are states where the problem of maternal mortality is not that severe as compared to other parts of the country. Southern states like Tamil Nadu, Kerala have current MMR of 97 and 81 respectively which has come down from 111 and 97 respectively.(Live births, maternal deaths, maternal mortality ratio in India by state from 2001–2003, 2004–2006, 2007–2009 special survey of death. Source: RGI 2009–2010)
The MMRs vary across the states, with the large North Indian states contributing a disproportionately-large proportion of deaths. Uttar Pradesh and Rajasthan, for example, have high rates of fertility and maternal mortality while Kerala and Tamil Nadu have rates comparable with middle-income countries. (Vora.K etal, 2009. Maternal Health Situation in India: A case study)
The medical causes for maternal deaths can be classified into three categories:Direct, indirect and co-incidental. Direct causes are complications that develop during pregnancy. These include Haemorrhage (antepartum and postpartum), abortion, ectopic pregnancy, hypertension, obstructed labour, puerperal sepsis. The indirect causes are causes which are present before pregnancy and get aggravated by pregnancy. These include heart diseases, anaemia, essential hypertension, Diabetes mellitus, malaria, tuberculosis. Coincidental causes include Road traffic accidents. (Royston, E and S. Armstrong. 1989. Preventing maternal deaths. Geneva.).
Haemorrhage is the leading cause for maternal death. 38% of maternal deaths occur due to that. Sepsis contributes to 11% of the total cause. 5% of maternal deaths occur due to hypertension and obstructed labour each. While even though the laws in India related to abortion are liberal, abortion accounts to 8% of maternal deaths. Other causes include anaemia which accounts to 34% of total cause. Nearly 60% of pregnant women are anaemic, especially due to iron deficiency (Vora.K etal, 2009, Maternal Health Situation in India: A case study). Prevalence of anaemia in India is among the highest in the world. Prevalence of anaemia is higher among pregnant women.((Kaivaik. K. 2009. Prevalence and consequence of anaemia in pregnancy.)
Determinants of maternal mortality in India are medical causesand social factors. A large number of social factors influencing maternal mortality like age of the mother, age of marriage, parity, birth spacing, family size, malnutrition, poverty, illiteracy.(Joshi and Kushwah.2011.An epidemiological study of social factors associated with maternal mortality in the community development block of Madhya Pradesh.)
. “Illiterate mothers and mothers from the lowest wealth quintile used basic maternal healthcare much less than their literate or wealthier counterparts and were far less likely to see a doctor. Only 18% of 39,677 illiterate mothers had institutional deliveries compared to 86% of 39,677 mothers with 12 or more years of education; similar differences were observed in the use of skilled care at delivery and use of postnatal care. Women of low economic status had availed 13% of institutional deliveries compared to 84% by women of the high wealth quintile. Only 19% of mothers of the lowest wealth quintile received postnatal care compared to 79% of mothers of the highest wealth quintile. These statistics reflect the inability of the public-health system to reach out to the poor and illiterate.”(Vora.K etal, 2009. Maternal Health Situation in India: A case study)
According to Vora.K etal, 2009. Maternal Health Situation in India: A case study and also the National Family Health Surveys (NFHS2005–2006) Institutional deliveries have risen from 26% to 39%, and nearly half of the women now have their births attended by health personnel. Postnatal care remains the most neglected area with only 42% of women receiving such care within two months of delivery, and a negligible number of women are visited in the vulnerable first week after delivery.
Poor nutritional status during pregnancy is another contributing factor towards maternal deaths. 65% of women stated that they received Iron-Folic acid tablets during pregnancy. Despite the emphasis given by the government, more than half of women don’t complete the antenatal check-ups and fail to receive tetanus prophylaxis.(Vora.K et al, 2009. Maternal Health Situation in India: A case study)
Another study reflects that the reasonswhy majority women don’t avail hospital treatment arefinancial constraints, ignorance,
Illiteracy, late decision, male dominance in family matters.Male counterparts are mostly responsible for the year gapping between having children, use of contraceptive, antenatal check-ups, Treatment of complications during pregnancy .Another factor contributing to maternal death is the age of the mother. The optimal age group is 20 to 30. Any further deviation from this increases the risk of maternal mortality during or after pregnancy.(Joshi and Kushwah.2011.An epidemiological study of social factors associated with maternal mortality in the community development block of Madhya Pradesh.)
Another factor contributing to a high maternal mortality ratio in India is the inadequacy of infrastructure and manpower. At present there are 370 district hospitals, 1762 first referral units, 4045 community health centres and 23,370 primary health centres in the country and there is deficiency of skilled manpower. 50% of community health centres and 30% of first referral units lack anaesthetists and obstetricians.
Emergency Obstetrics Care is adversely affected in many parts of the country. 30% of Primary health centres don’t have proper infrastructure. 70% of the first referral units and community health centres don’t have linkages with district blood bank. (Kumar.S.2010. Reducing maternal mortality in India: Policy, equity and quality issues.)
Biases in service delivery and inequitable distribution of health services is also a cause for concern in reducing maternal mortality. 30–40% of dalit women or the schedule caste reported denial of visit by the health workers, 20–25 % were reported being denied access to maternal care at private health centre, 10–15 % reported being denied access to maternal health care at primary health centres.
80% of maternal deaths occur in poor families. Out of which 61% are from the lower caste and 37% are from the schedule caste and 24% are from schedule tribe. (Kumar.S.2010. Reducing maternal mortality in India: Policy, equity and quality issues.)
In India the concept of child marriage still holds true. Girls are married before the legal age of 18 years. Child marriages are due to a mix of poverty, lack of education, social pressure. Early marriage and early pregnancy increase the risk of complications or death due to pregnancy. The medical risks associated with early pregnancy are hypertension, eclampsia and pre-eclampsia, postpartum haemorrhage. Girls who are married young lack information regarding pregnancy and healthcare, opt for deliveries at home by an unskilled professional or Dai or midwife.
REFRENCES
Maternal Mortality in 1990–2008.WHO, UNICEF, UNFPA and The World bank maternal mortality estimation Inter-Agency group India. [Online] [Accessed 2010].Available from:http:/www.who.int/gho/mdg/maternal_health/situation_trends_maternal mortality/
Live births, maternal deaths, maternal mortality ratio in India by state from 2001–2003, 2004–2006, 2007–2009 special survey of death. [Online][Accessed 2010].Available from http://nrhm-mis.nic.in/. Source: Registrar General of India, ministry of home affairs, SRS estimates.
Joshi and Kushwah.2011.An epidemiological study of social factors associated with maternal mortality in the community development block of Madhya Pradesh.
Vora.K et al, 2009. Maternal Health Situation in India: A case study.
Royston, E and S. Armstrong. 1989. Preventing maternal deaths. Geneva
Kaivaik. K. 2009. Prevalence and consequence of anaemia in pregnancy.
National Family Health Survey, India. (NFHS-3) 2005–2006. Source: www.nfhsindia.org/factsheet.html.
Kumar.S.2010. Reducing maternal mortality in India: Policy, equity and quality issues.