Maternal Mortality Rate — a key deterrent to Punjab’s development

Punjab has made numerous interventions in health and allied sectors, however, the Maternal Mortality Rate (MMR) remains a statistic of concern. The last decline was by 6.9 per cent in 2014–16. The Government of Punjab’s socio-economic survey for 2020–21 shows the MMR is stagnant at 122 and stands at par with the national average. More recent data from the Registrar General of India shows Punjab’s MMR has actually increased to 129 in 2016–18 while the national average is down to 113; WHO recommends an MMR of below 70.

Source: unicef.org

What impacts MMR?

Several factors impact MMR growth, some notable ones are:

1. Inadequate ante-natal care.
2. Significant cases of post-partum haemorrhage and bleeding due to anaemia.
3. Inability to ensure 100 per cent institutional (hospital) births or presence of a trained professional during birth due to social practices like home birth without professional care.

So, why isn’t the state able to bring down MMR?

First, the role of antenatal care is being underscored. The government’s own data highlights that while 90.5 per cent of expecting mothers gave birth in a healthcare facility only 30.7 per cent received the required antenatal care. Regular health check-ups facilitate early detection of pregnancy risks, enabling the doctors to tackle them at the time of delivery. Therefore, any argument about most deliveries happening at health care facilities in the context of MMR appears to be myopic in this case. This problem is not recent, even the erstwhile Planning Commission’s documents cite the 1998–99 Household Survey and point out the low ante-natal care coverage in Punjab.

The 2020–21 Economic Survey of the Punjab Government prides itself for implementing the Prime Minister’s Surakshit Matritva Abhiyan (PMSMA) — a scheme aimed at providing at least one antenatal check-up during the 2nd or 3rd trimester. Despite this, several districts in Punjab have noted significant maternal deaths in 2018–19 and 2019–20 (see table below).

Source: The Pioneer (data up to Dec 2020)

So why is the programme not yielding the anticipated outcomes? An expectant mother who visits an OBGYN at least once every trimester may be thought of as an aware expectant mother. The issue, therefore, is not just one’s ability to afford but an expectant mother’s or other involved stakeholders’ awareness level. The most striking feature of PMSMA is free health check-ups on the 9th of every month. An assessment of the Information, Education and Communication (IEC) materials, suggests a problem with the communication aspect of the policy. Most of the IEC content is focused on stakeholder appeasement and focuses too little on the date of the said event.

A cursory reading of the operational guidelines suggests that the Health Ministry recommends IEC material to be propagated and produced in local languages. But the fact remains, that the audio-visual IEC material for each of the stakeholders — be it private OBGYN or the family of an expectant mother or the mother herself, the content is too elaborate and almost entirely dilutes the importance of the event date. As a child born in the 90s, I still remember advertisements about Pulse Polio and wall paintings everywhere in addition to the door to door “2 बूँद ज़िंदगी की” (2 drops of life) and how dominant the Pulse Polio event dates were in addition to the involvement of celebrities like Amitabh Bachchan, Sachin Tendulkar, Shahrukh Khan, Hema Malini and Aishwarya Rai. Notably, UNICEF even has a dedicated portal for Polio IEC material.

Therefore, for PMSMA to work in Punjab or any other state in India, an aggressive communication campaign is required. Something on the lines of, “9 तारीख़ 9 बार 9 महीने तक” might do much better than current IEC approaches. In sum, a Pulse Polio-like aggressive IEC approach will help yield optimum results for the PMSMA programme and enhance the antenatal care levels in states like Punjab.

Second, Punjab needs to learn from the success stories of other Indian states like Andhra Pradesh. AP’s MMR stood at 154 in 2004–06 and fell to almost half to 74 for the 2014–16 period. As per the 2016–18 bulletin by the Registrar General of India, this further fell to 65. In contrast, Punjab went from 122 in 2014–16 to 129 in 2016–18.

How did AP achieve this? No single initiative can be credited as the sole reason behind Andhra Pradesh’s gradual MMR decline. Initiatives ranging from deployment of specialists in First Referral Units (FRUs), Talli Bida vehicles for transportation to referral hospitals in addition to the existing ambulance network, creation of additional blood banks and blood storage facilities at FRUs, implementing a KPI-based approach through the use of Safe Childbirth Checklists (SCC) and partographs alongside a focus on maternal health training seemed to have worked. This was complemented by few health infrastructure upgrades mostly, technology-based.

Third, lack of stringent focus on causes of maternal mortality like loss of blood during childbirth and postpartum haemorrhage might be causing the stagnation in MMR. There exists a possible causal link between anaemia and increased risk of blood loss during childbirth. Learning from the experience of Andhra Pradesh, a largely undiscussed reason behind the decline of maternal mortality cases might also be a parallel focus on reducing anaemia in the state. Anaemia management is an integral part of antenatal care and has been an important focus of successive governments in Andhra Pradesh.

Data on maternal deaths in AP and Punjab shows Punjab’s inability towards addressing a known cause (bleeding) of maternal deaths (see table). While the bleeding incidents in cases of maternal deaths reduced in 2012–13 and 2013–14, they again rose by 2.5 per cent in 2015–16. Between 2010 and 2016, the absolute decline noted by AP was 8.7 per cent whereas, for Punjab, the same stood at 2.4 per cent. However, Punjab did experience an MMR boom in the 2011–12 period wherein it experienced a growth of 7.2 per cent and has come a long way from there. A study from 2018 indicates that anaemia prevalence increased in Punjab despite numerous interventions. In contrast, AP noted a marginal decline over the years. In 2018, then Chief Minister Chandrababu Naidu even asked the Anganwadi workers to ensure the elimination of anaemia cases within a year. Perhaps, Punjab needs a consistent strategy to address anaemic cases in the state. A 45-day testing and treatment campaign like the one organised in 2019, seems illogical to address a persistent challenge.

Fourth, train Traditional Birth Attendants (TBAs), also known as “दाई माँ” (dai ma). While over 90 per cent of births happen in hospital or hospital-like settings, the remaining births do not. It is possible and in the context of Punjab, highly plausible that the TBAs account for these births. The government must give minimum training to these TBAs.

Fifth is the inability to recognise and utilise the existing Accredited Social Health Activist (ASHA) and Aanganwadi Worker (AWW) network.

In sum, the state of Punjab must do the following:

1. Ensure an enhanced and more stringent focus on ante-natal care. This can be done through the implementation of WHO-recommended interventions such as 4 essential visits to the OBGYN during the pregnancy period. A direct and persuasive marketing plan must also be implemented for the ante-natal care programmes in the state; date posters and direct messaging should remain the focus.
2. Prepare a long-term strategy to address anaemia patients in the state. Ensure testing and treatment facilities in every district. These may be complemented by a hierarchical referral system.
3. Train TBAs and integrate training sessions with PMSMA. TBAs or dai mas must at least be trained in understanding high-risk pregnancies and protocol for a referral. A possible approach can be organising training sessions for them closer to the PMSMA check-up sessions that are organised on the 9th of every month. Thus, motivating TBAs to act as an agent to spread awareness about PMSMA.
4. Reward AWW through an improved remuneration scheme. This will help and complement all other efforts as well. A minimum salary of Rs. 10,000 for ASHA and AWW as well as Rs. 25,000 for Anganwadi supervisors along with a committed annual increment will go a long way in recognising the efforts of these workers at the grassroots level.