Maternal mortality in India: The silent epidemic

July 2011

Reports about India being among the five countries with worst maternal mortality rate are shocking. For a developing country set to become a leading global player in the near future, such figures are reflection of poor attention paid to accessible healthcare. Some causative factors are discussed along with possible solutions.

Maternal mortality is defined as 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.

Maternal mortality is not only a medical issue but it also reflects the social, economic and cultural disadvantage that women face in a society. Most maternal deaths are avoidable and should ideally be avoided. However, in developing countries, the contributory factors are abject enough to create an abyss between pregnant women and essential comprehensive care. India lags far behind its contemporaries in getting on track to achieve Millennium Development Goal of 109 maternal deaths per 100,000 live births by 2015. Among South Asian nations, India’s performance in terms of maternal mortality is worse than countries like Bangladesh and Sri Lanka (maternal mortality = 50).

In 2006, on an average 254 women died giving birth to a child for every 100,000 live births; down from 327 in 1990. The states of Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttaranchal had the highest numbers ranging from 312 to 480. For India, the percentage of deliveries with skilled care went up from 33 per cent in 1990 to 52 per cent by 2007-08 – but this is still short of the developing world average of 63 per cent. (United Nations Development Programme, 2010)

There have been advancements in maternal and newborn care but in silos. There is a dire need to address this matter on all fronts simultaneously. Some of the factors that actively contribute to maternal deaths are listed here.

Adolescent pregnancy

Early marriage combined with lack of education and awareness about contraception has proved to be a lethal contributor to increased maternal mortality. This tradition is so deep-rooted in society that adolescent pregnancies continue in spite of severe legislation (Child Marriage Restraint Act 1978). About 50 per cent girls are married by 18 years of age, which creates insurmountable hurdles in terms of continuing education, making contraceptive decisions, financial and social independence. Societal expectations continue to result in teenage pregnancies and maternal deaths resulting from such cases are not always reported.

Adolescent pregnancy is common with a higher maternal mortality. Girls aged 15-19 are twice as likely to die from child birth as women in their 20s; those under age 15 are five times as likely to die. The health of average adolescent in India is seldom conducive to gestation. Anaemia and stunting are widely prevalent, especially in girls. Unmet need for contraception is very high (27 per cent in 15-19 year olds). Certain behavioural norms associated with marriage ensure that the freedom of decision may lie with an uneducated man of the house, rather than the educated woman. (Facts about adolescents in India, 2008)

Access to skilled care

Access to care is evidently the most important cause for maternal mortality in rural India. The phenomenon is more pronounced in Northern and Eastern states. Most rural women are daily wage workers who support their families financially. They are also homemakers who anchor their families and community. Access to care is most difficult in the most remote parts of the terrain. Women have to travel in order to reach services. The cost of transport and care are additional burdens along with leaving behind any older children or elders in the family. It is hardly surprising that women fail to access timely Antenatal Care (ANC).

Midwives and home deliveries still remain the first choice for people who cannot afford to leave their homes for various reasons. With almost 60 per cent of births occurring at home, India faces a variety of challenges in providing high quality maternal child healthcare. The level of knowledge about safe birthing practices may be low among traditional birth attendants. Access to trained skilled birth attendance is still lacking.

To counter this, the central government has undertaken several initiatives under the National Rural Health Mission programme. But skilled birth attendance is still an unrealised goal for much of the population. The Janani Shishu Suraksha Yojana launched recently by the Ministry of Health is the latest addition. Its predecessor, the Janani Suraksha Yojana involved use of conditional cash transfers to poor pregnant women for institutional delivery. This programme resulted in sharp increase in the numbers of women availing institutional facilities from 10.841 to 13.46 million (between 2005 to 2009). However, this has not translated to complete cure.

Medical causes

Haemorrhage, sepsis and anaemia are the major causes of maternal deaths, more so in rural areas. Moderate and severe anaemia among pregnant women (28 per cent) is almost double that of non-pregnant women (16 per cent).  According to NFHS III, only 51 per cent of mothers received antenatal check-up (at least three visits), 71 per cent received two or more doses of tetanus toxoid and contraceptive prevalence is 56.3 per cent in 2005-06. Ironically, all of these are avoidable scenarios, which can be prevented with access to reachable, affordable and high quality care.

Overall health status of the woman, reproductive status, contraceptive measures practices, access to health services and utilisation of services are all known indicators of reproductive health of the nation and they all are essential fronts needing improvisations. Birth events too close to each other is an acceptable trend in the Indian society, without any thought for its medical implications. (Country Health System Profile, 2007). There is an urgent need to educate women about medical aspects of consecutive pregnancies and the effects on both mother and newborn and empower them for contraceptive usage.

Need for centralised registry

Practitioners and Traditional Birth Attendants (TBAs) lack a clear understanding of which deaths to classify as maternal deaths. Almost 30 per cent of women in India deliver at home and such cases may not be reported. Several deaths also occur in transit while reaching the hospital. These too are not reported as maternal deaths. At present, there is no central registry where such cases can be reported. Deaths are reported to local authorities and may not always be categorised as maternal deaths. The creation and monitoring of such a registry can also help in identifying key problems and devising focussed solutions.

Challenges in addressing maternal mortality

It is not possible to predict which mother will develop complications. Every woman, irrespective of socio-economic status is equally at risk and hence the high-risk approach does not help much

Most complications cannot be prevented by good ANC. Hence, ANC alone cannot prevent maternal mortality

Cost-effective approach to reducing maternal mortality by ensuring high quality emergency obstetric care (EmOC) to mothers who develop complications during delivery

Need for decisive action

Dr Sanjay Gupte, MD, DGO,FICOG, FRCOG,LLB,President FOGSI 2010

Women’s health issues continue to be marginalised with limited or no social standing. Death of a pregnant woman is not only a reflection of access to health in a society but also a matter of grave social injustice. Not only the woman but her family and community at large are gravely affected by death of a mother. It has been observed that survival of a newborn after the mother’s death is gravely affected.  In spite of the multiple roles a woman plays, the role of a nurturer, an educator and a role model is still the most important for all children, everywhere in the world.

It is indeed shameful for any nation to have high rates of maternal and newborn deaths, especially so for a country, which is fast becoming a global player. It is time for India to tackle maternal mortality head on and promise safe motherhood for every one of its women and a healthy mother for every newborn child.

(mmedit@infomedia18.in)