MATERNAL MORTALITYIn India

By Aayupta MohantyGroup no. 55th year 1st semester

INTRODUCTION“The challenge to human rights principles is to make the

promise of safe

motherhood real. The opportunity of advancement through ensuring respect

for human rights has been recognized nationally and internationally, and the

language of human rights has come to define the best enjoyments of life that

countries can offer their populations.”

Maternal mortality is defined as “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.”

In 2010, countries with highest maternal mortality were Chad(1,100), Somalia (1,000), CentralAfrican Republic, (890), Sierra Leone (890) and Burundi (800)

Lowest rates included Estonia at 2 per 100,000 and Singapore at 3 per 100,000.

THE SITUATION IN INDIAMATERNAL MORTALITY: AN ONGOING CRISIS

In India, roughly one maternal death occurs every five minutes. According to the government, these deaths account for 15% of all deaths of women of reproductive age.

Data from the most recent National Family Health Survey (NFHS-3) suggest that the maternal mortality ratio has fallen fromapproximately 400 deaths per 100,000 live births in 1997 it has come down to 212 per 100,000 live births in 2007-09 i.e. a decline by 115 points in the last 10 years. Thus, the country has reduced MMR by an average of 11 points per year. In view of this there is likely to be a decline of another 50 to 60 points by 2015 i.e. country may attain MMR of 162.

To achieve the millenium development goal on maternal health, India is needed to reduce MMR from 437 deaths per 100,000 live births in 1991 to 109 by 2015. It has only reached the 212 mark just yet. Long way to go ….

MATERNAL MORTALITY IN 1990-2010WHO, UNICEF, UNFPA,THE WORLD BANK AND UN POPULATION DIVISION MATERNAL MORTALITY ESTIMATION INTER-AGENCY GROUPINDIA

YEAR MMR MATERNAL DEATHS

LIVE BIRTHS

PROPORTION OF MATERNAL DEATHS OF REPRODUCTIVE AGE

Lifetime risk of maternal death

2010200 (140–

310)

56,000 (38,000–83,000)

27,146

7.4 (5.1–10.8) 170

2005280 (190–

420)

76,000 (51,000–113,000)

27,220

9.4 (6.4–13.9) 110

2000390 (260–

600)

107,000 (72,000–163,000)

27,300

12.2 (8.3–18.3) 73

1995480 (320–

730)

132,000 (88,000–202,000)

27,554

16.0 (10.8–24.0) 53

1990600 (390–

920)

163,000 (109,000–252,000)

27,329

20.3 (13.7–30.8) 38

DOCUMENTATION GAP Since many deaths happen in the anonymity of

women’s homes or on the way to seek help at a medical facility, they often go unrecorded. Absence of official registration and auditing for maternal deaths.

In response to the lackof accurate and complete national government data on maternal mortality, several forms of maternaldeath auditing have been developed as accountability measures in India, including the United Nations Children’s Fund’s (UNICEF)

1) Maternal and Perinatal Death Inquiries and Response (MAPEDIR) –verbal autopsy method

2) Academy of Nursing Studies’ (ANS) maternal death social audit.

State governments are particularly well placed to undertake such studies

CAUSES OF DEATH AND MORBIDITY Medical causes Socioeconomic causes Health system related factors

MEDICAL CAUSES

Anemia and unsafe abortion are deserving of special note, as these two causes of maternal deathare more common in India than they are in much of the world.

anaemia-Pregnant women who are anemic, face multiple health risks in addition to the risk of maternal death. Anemic women are increasingly susceptible to communicable diseases such as tuberculosis (TB) and malaria, which are associated with adverse outcomes during andafter pregnancy.

Anemia is a contributory factor in maternal deaths caused by hemorrhage, septicemia and eclampsia,and when severe can even cause cardiac arrest.

Unsafe abortion-Complications from unsafe abortion account for a significant proportion of maternal deaths inIndia.

According to the government, around 9% of total maternal deaths are caused by unsafe abortion,but medical experts put the figure at almost 18% higher than the global average of13%.

Although abortion is legally permitted on several grounds, each year approximately 6.7 million abortions occur outside of government-recognized health centers, often in unhygienic conditions or by untrained abortion providers. This problem disproportionately affects adolescents, as unsafeabortions account for half of all maternal deaths of women aged 15-19.

SOCIOECONOMIC FACTORS

A higher incidence of mortality and morbidity is found to occur among woman and girls who are

poor or low-income, less educated and belong to socially

disadvantaged castes and tribes. Child marriage puts young girls and

adolescents at significant risk of pregnancy-related complications andmortality.

Pregnant women living with HIV/AIDS experience an increased risk of pregnancy-related fatalities due to outright discrimination

HEALTH SYSTEM RELATED FACTORS

Geographical vastness and socio-cultural diversity in India indicates that maternal mortality varies across the states, and therefore uniform implementation of health-sector reforms is a tall task.

Maintaining healthcare standards at the grassroots level requires interdisciplinary cooperation and collaboration among doctors, midwives, auxiliary nurses and other paramedical staff.

The provision of healthcare at the terminal end of healthcare system in the rural areas urgently requires a well intended political drive to improve the present scenario.

The high MMR is due to large number of deliveries conducted at home by unskilled persons with zero compliance to basic hygiene standards.

Added to this, lack of adequate referral facilities to provide emergency obstetric care for complicated cases also contribute to high MMR.

The three delays Most maternal deaths are attributable to the ‘three delays’: the delay in

deciding to seek care, the delay in reaching the appropriate health facility, and the delay in receiving quality care once inside an institution.

the declining numbers of MMR within the states of Maharashtra, West Bengal, Tamil Nadu, and Kerala, indeed brings some respite.

Strengthened ante-natal care (ANC): This was done by conducting maternal medical campaign that included early registration of ante-natal case (i.e. pregnant mother) before 12 weeks, conducting baseline investigations – haemoglobin, blood pressure, weight, height, body-mass index, urine-albumin/sugar, HIV testing, sonography. These investigations are done for identifying high risk factors such as high BP, protienuria, anaemia, twins, hydramnios, IUGR etc.

Distributing free medicines, conducting screening programmes for high risk pregnancies such as short stature, multipara, elderly primigravida, through clinical examination of ANC is done during these ANC visits and by creating a mother & child tracking system (MCTS) wherein all mothers and children are tracked and provided services from time to time, resulting in increasing ANC coverage.

Strengthen intra-natal care and post natal care (PNC): This was done by ensuring 100 per cent deliveries at institutions by micro – birth planning by way of keeping a track of the mother throughout the pregnancy term and well up following up with the delivered mother on 2nd, 7th, 10th Day and for baby on Day – 7, 14, 21, 28 and 42 day

National Targets and Initiatives

Infrastructure strengthening: The government has mapped all health facilities available in the state. The government has also strengthenied sub centres, primary health centres (658) as per Indian Public Health Standard (IPHS) norms, strengthening of first referral units (220). In addition, the government has also provided for blood transfusion facilities at most of these centres, free referral transport services for these women, free diagnostics and medicines, free diet during stay, and adequate PNC care is being implemented across the state.

Strengthening of manpower: The government of Maharashtra provides forvarious trainings are being taken such as,skilled attendant at birth - (ANM/LHV/Staff Nurse): 7038 trained

Basic emergency obstetric care training: 4372 trained Comprehensive emergency obstetric care training:133 trained Life saving anaesthesia skill training of MOs:173 trained

Maternal death review is a tool used to review all facility-based and community-based maternal death. Started in the state since 2010 as per government regulation dated May 28, 2010. This process has helped the state in identifying the type of delays, reasons for delay and the system gaps which are responsible for maternal death. State has been identifying gaps and implementing the corrective measures.

Janani Suraksha Yojana (JSY): Under the JSY, the state provides for conditional cash transfer scheme. The beneficiaries must be BPL. In case of SC and ST, benefit should be given to all pregnant women (including non BPL). The age of pregnant mother should not be less than 19 years. The benefit should be given to the beneficiaries up to two living children. For home delivery, Rs 500 is to be given to the BPL beneficiary only. The beneficiary from urban area, if she delivered in a health institution gets an amount of Rs 600 within seven days and those from rural areas get Rs 700 within seven days. In case of Lower Segment Cesarean Section (LSC S), Rs 1500 is to be given to the beneficiary if she has undergone caesarean section delivery in private accredited hospital.

“The scale of maternal mortality is an affront to humanity…The time has come to treat this issue as a human rights violation, no less than torture,disappearances,arbitrary detention, and prisoners of conscience.” – Mary Robinson, former UN High Commissioner for Human Rights