All About Issue Of MMR In India

Governance Issues Health

India’s Maternal Mortality Ratio (MMR) has seen a decline from 130 per 1 lakh live births in 2014-2016 to 122 per 1 lakh live births in 2015-2017, according to the latest Sample Registration System (SRS) 2015-2017 bulletin for MMR.

However, India’s current MMR is still higher than the sustainable development goal (SDG) target–a set of globally agreed goals that India has signed on to–of 70 deaths per 100,000 live births for the world by 2030.

What is maternal death?

According to the 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.
India accounts for 17 per cent of the global burden of maternal deaths. The leading causes of such deaths in India are haemorrhage (38 per cent), sepsis (11 per cent) and abortion (8 per cent).
The major cause— Post-Partum Haemorrhage is often defined as the loss of more than 500-1,000 ml of blood within the first 24 hours following childbirth.

Maternal Mortality situation in the country

11 States have achieved the National Health Policy target of MMR 100 per lakh live births well ahead of 2020
Three States Kerala (42), Maharashtra (55) and Tamil Nadu (63) have already achieved the UN’s Sustainable Development Goal of MMR 70.
The decline has been most significant in EAG States from 188 to 175.
The ratio has reduced considerably from 77 to 72 per 1,00,000 live births among southern states and in the other states from 93 to 90.
Independent MMR data of Jharkhand (76), Chhattisgarh (141) and Uttarakhand (89) has been released for the first time.
Rajasthan’s MMR has shown the highest decrease by 13 points, followed by Odisha (12 points) and Karnataka (11 points).
While Karnataka has shown the highest percentage decline in MMR, Uttar Pradesh and Madhya Pradesh have shown an increase by 15 points each in MMR.

Classification of states:

The government has categorised states into three groups: empowered action group (EAG), southern States and other states.
Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh/Uttarakhand and Assam fall under the EAG and Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu are in the southern States group. “Others” comprise the remaining States and Union Territories.

Rural-Urban divide:
- The rural-urban divide is considerable when it comes to healthcare access. Fairly-developed states like Kerala, Maharashtra and Tamil Nadu have brought down their IMR, TFR and MMR rates and states like Assam, Jharkhand continue to grapple with these issues even today.
- As per the NFHS-4 survey only 16.7% of women in rural India received full antenatal care (ANC)’, which is about half the women in urban areas (31.1%).
- The urban-rural divide in institutional births: Overall 75 percent of rural births are now supervised as compared to 89 percent in urban areas.”
- Average total medical expenditure per childbirth in a public hospital: Rs 1,587 in a rural area and Rs 2,117 in an urban area.

Reasons behind MMR:

Rising Inequalities: Education and learning outcomes at schools, high rate of population growth can be traced to existing socio-economic inequalities.
Pre & Post Natal Care Interventions: The World Health Organisation (WHO) recommends at least four ANC visits for every pregnant woman but it is often neglected.
Child marriages: When girls bear children while they are still children themselves, their lives are put at risk. Complications in pregnancy and childbirth are the leading cause of death in girls aged 15-19 in low- and middle-income countries.
Frequent pregnancies: Many families in rural India assume that more children mean more hands to work. With constant pregnancies and societal pressure to deliver a son, a woman's body undergoes extreme stress for months and years.
Lack of Reproductive Rights to Women: The National Family Health Survey (NFHS-4) 2015-16 shows that less than two-thirds (63%) of married women have any say in their own health care or other household decisions.
Non-Institutional Deliveries: high rate of home delivery and delivery by unskilled birth attendant-all can lead to high maternal mortality ratio (MMR).
Patriarchal Society: patriarchal customs make women’s health, nutrition and education unimportant
Poor Infrastructure & Facilities at PHCs: States with large number of PHCs functioning with just one doctor or without a doctor are indicative of relatively higher rural Infant mortality rates (IMR) and maternal mortality ratio (MMR),” according to the Economic Survey 2018-19.
Unsafe abortions: If women are not allowed to terminate their pregnancy legally after 20 weeks, they will either go abroad for abortions or terminate it illegally. This will lead to unsafe pregnancies.
Barriers to utilization of anganwadi services by pregnant women and lactating mothers: Awareness regarding Anganwadi services available for pregnant and lactating mothers like IFA, calcium and deworming tablets, TT and health check-ups was found to be poor.
Illiteracy and lack of education: With the poor growth in quality education over the past many decades impacts maternal health and care. It is a known fact that an educated and empowered woman is less likely to have multiple unwanted pregnancies.
Unnecessary caesarean sections: Poor access, unnecessary caesarean operations, late referrals, inappropriate procedures, poor resources and training of medical practitioners are major reasons for maternal deaths following caesarean sections.
Low use of contraceptives:
- According to NFHS 4, female sterilisation in India continues to be around 37 per cent since 2006, despite health complications and deaths, highlighting the gender inequality in contraceptive use.
- This could be because of lack of accessibility or awareness of other contraceptive methods and requires immediate redressal.
- With male sterilisation on rapid decline, Ministry of Health and Family Welfare released the National Health Policy 2017 which aims uptake of male sterilisation to 30 per cent.
- Sex determination tests: In Bihar, a state among those with high MMR in India, it was found that forced abortions after sex determination tests and lack of ambulances are major reasons for maternal deaths.
The lack of proper nutrition for pregnant women: The NFHS-4 survey says that ‘only 30.3% of Indian women consumed iron and folic acid tablets for the recommended course of 100 days or more. As a result, 50.3% of pregnant women and 58.4% of children aged 6-59 months had iron-deficiency anaemia (a major cause of maternal deaths, pre-term births and infant mortality)’.

Vicious cycle of poor maternal health and Child stunting

https://i1.wp.com/www.prb.org/wp-content/uploads/2003/07/p-PoorNutrition.gif?w=509&crop=0,0px,100,201px&ssl=1

Government Initiatives

The National Health Mission--which provides for universal access to equitable, affordable and quality health care services--is conceived as the primary tool to reach health targets: maternal mortality ratio (MMR) of less than 70 deaths per 100,000 live births, neonatal mortality rate (NMR) of 12 deaths per 1,000 live births and under-five mortality rate (U5MR) of 25 deaths per 1,000 live births.
The Janani Surkasha Yojna (JSY) scheme
- It has further strengthened maternal health initiatives by entitling free deliveries and Caesarean-Sections to every pregnant woman coming for deliveries at government health facility.
- The transport from the health facility, drop back and any referrals between facilities is also free for pregnant women coming to government health facility.
Pradhan Mantri Surakshit Matritva Abhiyan: Health ministry launched an innovative scheme to provide free health check-ups to pregnant women at government health centres and hospitals by private doctors.
“LaQshya” (Labour room Quality Improvement Initiative): The Union Health Ministry recently announced the launch of LaQshya, a programme aimed at improving the quality of care in the labour room and maternity operation theatre.
POSHAN Abhiyan and SUMAN (Surakshit Matritva Aashwasan Initiative) aim to ensure that all pregnant women receive quality maternal care with dignity and that no mother or newborn dies due to a preventable cause.
Reproductive Maternal Newborn Child Health+ Adolescent (RMNCH+A) :
- 184 High Priority Districts (HPDs) have been identified for implementation of RMNCH+A interventions for achieving improved maternal and child health outcomes.
- RMNCH+A Links maternal and child survival to other components (family planning , adolescent health, gender & PC & PNDT)
- Focus on Aspirational Districts

NITI Aayog identified 117 aspirational districts across 28 States for transformation by the year 2022

‘I pledge for 9’ : It invites the private sector to provide free ante-natal services (ANC) on the 9th of every month on a voluntary basis to pregnant women, especially those living in underserved, semi-urban, poor and rural areas.
Draft MTP (Amendment) Bill, 2019: It drafted “for cases in which doctors diagnose foetal abnormalities or substantial risks to the mother or the child. If women are not allowed to terminate their pregnancy legally after 20 weeks, they will either go abroad for abortions or terminate it illegally. This will lead to unsafe pregnancies.

MTP is a health care service and right to terminate pregnancy is firmly embedded in multiple rights - the right to health, right to life, right to scientific progress, right to privacy and right to choice.

Concerns with Govt’s Policy

Poor fundings:

As per the National Health Profile 2019, between 2009-10 and 2018-19, India’s public health spend as a percentage of GDP went up by just 0.16 percentage points from 1.12% to 1.28% of GDP.

India’s National Health Policy 2017, framed in line with the SDGs, prescribes increasing the health expenditure of states to more than 8% of their annual budgets by the year 2020, but the seven states evaluated spent between 3.29% and 5.32% for the period of 2012-2017, according to a CAG report.

Allocations to the National Health Mission fell short by 13.6% in 2018-19 compared to the budget projections, according to the CAG’s report.

State spending on health yet to increase:

To reach the 2025 target of spending 2.5% of GDP on health, the National Health Policy mandated states to increase their health spending on primary care by at least 10% every year.
In addition, a 4% health and education cess was also proposed which was not implemented.

Health shortages affect progress:

Rural India has a shortfall of between 24% and 38% in the number of sub-centres, primary health centres (PHC) and community health centres in 28 states and union territories.
The population-doctor ratio in India was 11,082:1 in 2017 in government hospitals, 25 times higher than the World Health Organization recommendation of 25 professionals per 10,000 population.

Dearth of data:

The NITI Aayog, the government’s policy think tank and the body responsible for overseeing implementation of SDGs, and the statistics ministry in consultation with the state governments, were to prepare the National Indicator Framework, the backbone for monitoring of SDGs.
However, data for 137 of 306 national indicators were not available for 13 SDG goals.

Way forward

Strengthening PHCs through the NRHM
Enhancing Role of ASHAs & ANMs,:
- A proposal for certification of ASHAs through National Institute of Open Schooling (NIOS) has also been approved. States should Identify ASHAs who aspire to obtain academic qualification for Class X or Class XII and to support their registration with the National Institute of Open School (NIOS).
- For ANMs, States should undertake their skill assessment and train them as per the identified gaps besides providing training on skills like IUCD insertion, SBA etc.
- States have also been supported and encouraged to set up skill labs to refine their clinical skills.
Family Planning AwarenessTherefore, the focus should be on improving data for identifying the issues in contraceptive use and addressing gender inequality in SRHR in India.
Essential Drugs and Diagnostics: Ensure free essential drugs and diagnostics at all government facilities
Validation of data: Check for completeness & correctness of HMIS data /data from RCH portal
Addressing women’s malnutrition has a range of positive effects because healthy women can fulfill their multiple roles — generating income, ensuring their families’ nutrition, and having healthy children — more effectively and thereby help advance countries’ socioeconomic development.
Need for better data: Maternal death audits and reviews also need to be implemented to understand why, where and when women die and what can be done to prevent similar deaths.
- The role of the National Data Quality Forum (NDQF), a multi-institutional initiative hosted by Indian Council of Medical Research (ICMR) becomes crucial when it comes to addressing the gaps between data collection and analysis and using that data for advocacy and policy making.
Improving access to surgery, promoting appropriate use of the procedure, providing safe surgical environments,
Education of girls, avoiding early marriage, and ensuring gender equality.
Ensuring a wide range of contraceptive options is important to help women plan and space, and avoid pregnancies
Behavioral Change: It includes not reproducing after age 35; eating a healthy diet; limiting or avoiding alcohol consumption; stopping smoking; using a bednet to protect against malaria; arranging for a skilled birth attendant at labor and delivery; and recognizing and acting promptly on signs of a complicated delivery.
Antenatal Care, Nutritional interventions, Prenatal counseling to recognize signs of complications. At least four antenatal-care visits during pregnancy and delivery in the presence of a skilled birth attendant can help detect conditions that can lead to birth complications, according to the World Health Organization.
Skilled Attendance at Childbirth: Providing a skilled birth attendant during childbirth who has the knowledge and experience to use certain strategies when they are needed is a key step to reducing mortality and severe disability in childbirth.
Sexual and Reproductive Health and Rights (SRHR), which are fundamental for family planning and the overall well-being of individuals.

India is on track to achieve SDG target of MMR, however the four states namely Assam, Uttar Pradesh, Madhya Pradesh and Rajasthan will have to intensify their efforts to accelerate the MMR decline to achieve the SDG target.

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