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Indian Journal for the Practising Doctor

Maternal Mortality in India - Magnitude, Causes and Concerns

Author(s): Rehana Kausar

Vol. 2, No. 2 (2005-05 - 2005-06)

The extent of maternal mortality is an indicator of disparity and inequity in access to appropriate health care and nutrition services throughout a lifetime, and particularly during pregnancy and childbirth. National Population Policy 2000 and National Health Policy 2002 aim at reducing the Maternal Mortality Rate (MMR) to 100 per 100,000 live births from the current level of 400-500. Experts feel that at least 40% of all pregnant women will experience some type of complication during their pregnancies and about 15% of these complications will be potentially life-threatening and will require immediate emergency obstetric care. This is the very reason that the Indian Medical association (IMA) wishes institutional deliveries by skilled persons (doctor or nurse) which can be performed anywhere in both public or private existing health services. Maternal death also compromises the health and survival of infants and children they leave behind. The death of a woman during pregnancy and childbirth is not only a health issue but also a matter of social injustice.

Causes of maternal deaths
1. Direct Causes: 81%
  Severe Bleeding 25%
  Sepsis 15%
  Unsafe abortions 13%
  Eclampsia 12%
  Obstructed Labour 8%
  Other direct causes * 8%
2. Indirect Causes ** 19%

* Other direct causes: Ectopic pregnancy, embolism, anaesthesia related.
** Indirect Causes: Malaria, Anaemia, heart diseases.

Causes of Maternal Death in India

Analysis of the important causes of maternal mortality reveals that most of them are preventable. This makes the persistence of a high MMR for last 50 years more shameful, and indicates that we have not been able to establish appropriate maternal health services especially in the rural areas. An

improved, accountable health care system at primary level is essential for decreasing maternal mortality to the desired level.

Global Situation

Comparison of the 6 regions shows striking contrasts. While the rate is 11/100000 in North America, it is 100 times as high in Africa. The average for Southeast Asia is 275. Some countries of the Region have shown considerable success. However, India, Bangladesh, Indonesia and Nepal are fairing poorly.

The high incidence of maternal mortality is an indication that the perinatal care is very poor in our place. Though mothers form about 22% of the total population, we continue to neglect their health needs. Currently hardly any community health centre, the first referral unit under the over-ambitious Reproductive and Child Health Programme, enjoys the services of an obstetrician or a lasy assistant surgeon specially trained in obstetric practices.

Maternal mortality by world region in 1995, according to WHO
Region Number
of Maternal
Africa 273,000 1,000
Asia 217,000 276
Latin America 22,000 190
Oceania 580 110
Europe 2,200 28
North America 490 11
World Total 515,270 400

Missing Image

Situation in India (State-wise)

Estimates of MMR of some bigger states in India, 1998

India Rajasthan U.P M.P Bihar Orissa Kerala A.P T.N Gujarat
407 670 707 498 454 367 198 159 79 28

The Indian average is 407/100,000 live births. The so-called 'bimaro' states have consistently shown a figure that far exceeds the national average. Even Kerala, which has been able to bring its IMR to as low as 13, has not been able to trim MMR to the desired level of 100. Our State has always been having an MMR lower than the national average.

Reasons of High Maternal Mortality in India

The Main Reasons Behind high Maternal Mortality in India Are

Deliveries not attended by trained personnel:

NFHS-2 (The National Family Health Survey, conducted in 1998) reports that only one- third (34%) of deliveries in India take place in health care facilities and two- fifth (42%) of deliveries are unattended by a trained medical professional.

  • Women not seeking Antenatal Care; More than one out of every three women (34%) in India did not receive an ante-natal check- up for births in the three years preceding the survey. Only 7% received antenatal checkup in third trimester.
  • Postnatal care is grossly deficient.

Teenage pregnancy and their risk of dying:

Despite the Child Marriage Restraint Act (1978), 34 percent of all women are married below the legal minimum age of marriage (ie 18 years); the figure is higher in rural areas (40%) than in the urban (18%). Adolescent girls face considerable health risks during pregnancy and childbirth. Girls aged 15-19 are twice as likely to die from child birth as women in their twenties; those under age 15 are five times as likely to die.

(Teenage pregnancy is not only legally prohibited, it is a great biological hazard. One of the reasons is that the reproductive tract is not ready fully for all processes of conception & delivery. Another very important reason is that the mother is herself growing, and there is a competition between two children for nutrients which are scarce in the diet. This jeopardizes the growth & development of both the mother and her child. The result of such pregnancy is a malnourished mother and an LBW infant. (Ed) )

Reasons for under-utilization of services

Apart from non-availability or poverty of services, one reason behind increased maternal mortality may be non-utilization of such services by the mothers. Various factors are operative:

1) Women lack awareness of the importance of pregnancy care and delivery/taking place in a healthcare facility (poor health education).

2) Women's lack of decision- making power within the family (gender bias).

3) Lack of awareness of location of health services (poor health awareness).

4) Cost: direct fees as well as the cost of transportation, drugs and supplies (poverty).

5) The poor quality of services, including poor treatment by health providers also makes some women reluctant to use services.

Interventions and Solutions to reduce Maternal Mortality :

The persistence of a high MMR despite half a century of efforts to bring it down indicates that somehow we have not been able to establish appropriate maternal health services especially in the rural areas. An improved, accountable health care system at primary level is essential for decreasing maternal mortality to the desired level. We should

1) Make the antenatal, intranatal and postnatal services available to women, located close to them.

2) Ensure delivery by skilled attendant nurses or doctors.

3) Establish linking to hospitals by an emergency transport and good referral system of network.

4) Utilize big potential of primary health centres.

Peripheral/ Village level interventions specifically directed towards major causes of maternal deaths are required. The emphasis should be laid on the major causes of maternal deaths through peripheral/ village level heath care worker/ panchayat people and every pregnant woman should be aware of these entities.


"Safe Motherhood" has placed maternal mortality issue in the context of human rights, urging governments to use their political, legal and health systems to fulfill the obliga-tions imposed by their endorsement of various international human rights instruments. Making motherhood safer, therefore, requires more than good quality health services. Women and adolescent girls must be empowered and made aware of the legal age of marriage and their human rights including their rights to good quality services and information regarding care during and after pregnancy and childbirth.

IMA Pleads for Safe Motherhood - Institutional Deliveries; Make This a Movement Wherever You Are

Close to two-thirds of all deliveries in India still take place at home - the proportion varies from less than 35% in urban areas to more than 75% in rural areas. In states like Uttar Pradesh and Bihar, only about 15% of children are born in medical institutions.

It is often argued that there is nothing intrinsically wrong about women delivering at home. As a matter of fact, many of our readers have been born at home and are none the worse for it. Such simplistic reasoning, however, glosses over the fact that there is a huge difference in the situation and prospects of an urban middle-class woman and a woman from a poor family in a village in Uttar Pradesh or Bihar. The urban woman in probably well- nourished, has been going to a doctor regularly for check-ups, and has been given anti-tetanus injections. She will deliver in a clean place with a trained nurse in attendance and a doctor within reach in case of emergencies. For her, delivering at home is a matter of choice. The village woman, on the other hand, has a high chance of being anaemic and underweight, of not having seen a doctor and not being protected from tetanus. She would not have access to a doctor or hospital in her own village. For her, delivering at home, rather than being a conscious choice, is a consequence of her lack of choice.

(From Deliberations and Discussions in the Indian Medical Association Sponsored Women Doctor's Conference held in 2005 at Delhi)

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