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Indian Journal of Community Medicine

Trend in Maternal Mortality and some Policy Concerns

Author(s): Asha Rawal

Vol. 28, No. 1 (2003-01 - 2003-03)

Consultant Obstetrician and Gynaecologist
G-l1/17 SFS Naraina Vihar, New Delhi-28

Introduction:

The National Health Policy (1982) developed and approved by the parliament in 1983 soon after the Alma Ata Declaration (1977) on Health for all aimed at reducing the maternal mortality rate in India from the over 400 per 100,000 live births to less than 200 per 100,000 live births by the end of the year 20001,2. The commitment was reiterated in many national policy documents and country reports and National Plans of Action developed on the aftermath of many UN Summits and Conferences including the World Summit for Children, New York, the International Conference on Population and Development, Cairoand World Conference on Women, Beijing.

MMR in India

1980 - 82 753 Bhaskar Rao
1990 570 WHO/UNICEF
1992 - 94 572 FOGSI 3
1992- 93 437 NFHS-I 7
1997 408 SRS
1998 407 SRS
1998-99 540 NFHS-II

The estimates on maternal mortality in India have been very elusive and a speculation till the 1990's when more reliable methods and surveys included maternal mortality as an explicit item in their questionnaires. The 1990 joint WHO-UNICEF estimate on maternal mortality through a modelling exercise based on other indicators put the figure at 570 per 100,000 live births3. The project report on maternal mortality in India carried out by FOGSI through a study supported jointly by WHO and MOHFW suggested that the MMR in India has fallen to 572 per 100,000 live births from the earlier estimate of 1980-82 by Dr. Bhaskar Rao which had suggested that MMR was 753 per 100,000 live births4. Soon after, the National Family Health Survey carried out in 1992-93 estimated that at the national level the maternal mortality for the two years preceding the survey was 437 per 100,000 live births. Soon after, the Sample Registration System of the office of the Registrar General of India started collecting information on maternal mortality through SRS units and published for the first time in 1998 that the MMR estimates for 1997 was 408 per 100,000 live births. The report also published MMR estimates for various states and cautioned that the estimates in respect of Tamil Nadu and Gujarat are likely to be under-estimates. The exercise was repeated in the following year and the estimates only marginally fell to 407 which might even be explained as a statistical phenomenon and not necessarily reflective of reduction in maternal mortality in the country.

The most recent estimate, however, comes from the second round of National Family Health Survey conducted during 1998-99 and officially released in 2000. The estimate for the two years preceding the survey has put the figure at 540 per 100,000 live births. While the confidence limits of the FOGSI, WHO/UNICEF or 1997 SRS estimates are not known, the NFHS has published the 95 percent confidence limit for the first survey as ranging between 334 and 540 and in the following survey as ranging between 428 and 653. The SRS estimates of 1998 suggested ninety five percent confidence limits within a range of 351 and 463. What is concerning is the fact that we are far away from the goals set in the National Health Policy and each of the successive Plans of Action over theyears. The National Planof Action5 for children developed in 1992 committed to halve the MMR by the year 2000 from that in 1990; likewise, the National Child Survival and Safe Motherhood Programme6 launched in 1992 made a similar commitment. However, statistical phenomenon of confidence limits and not experience has shown that we are around the same levels necessarily reflective of the actual performance in mortality and the estimates may be low or high depending on the reduction.

Table I: Maternal mortality and quality of care by States in India.

State MMR-FOGSI
1992-94
MMR-SRS8
1997
MMR-SRS9
1998
% Received
ANC*
% Delivery in
Institutions**
% Trained birth
Attendant***
Andhra Pradesh 380 154 159 35.6 49.8 65.2
Assam 847 401 409 15.8 17.6 21.4
Bihar 1668 451 452 6.4 14.6 23.4
Gujarat 697 29 28 25.0 46.3 53.5
Haryana - 105 103 20.8 22.4 42.0
Karnataka 681 195 195 41.5 51.1 59.1
Kerala 223 195 198 64.9 93.0 94.0
Madhya Pradesh 1038 498 498 10.9 20.1 29.7
Maharashtra 345 135 135 331.0 52.6 59.4
Orissa 1292 361 367 21.4 22.6 33.4
Punjab 992 196 199 31.7 37.5 62.6
Rajasthan 634 677 670 8.3 21.5 35.8
Tamil NAdu 316 76 79 50.8 79.3 83.8
Uttar Pradesh 1359 707 707 4.4 15.5 22.4
West Bengal 1034 264 266 19.7 40.1 44.2
India 572 408 407 20.0 33.6 42.3

*Recommended ANC - three or more antental check ups (with the first check-up within the first trimester of pregnancy), two or more tetanus toxoid injections, and iron and folic acid tablets or syrup for three or more months - NFHS II (1998-99)10
**NFHS-II( 1998-99)
***Trained birth attendant if delivered by doctor, ANM, Nurse, Midwife, LHV or other health professional - NFHS-II (1998-99).

To understand the reasons, we need to briefly review two major aspects of Maternal Mortality in India. The first relates to the States where India has very high maternal mortality rates. The second is what are the major causes of maternal mortality in the country. MMR has not been estimated at state level in most of the studies. The FOGSI report and the SRS estimates have provided estimates of maternal mortality by major states. According to the FOGSI report, during the period 1992-94, the states of Bihar, Uttar Pradesh, Orissa, Madhya Pradesh, West Bengal, Punjab and Assam (in that order) have maternal mortality rates of over 800 per 100,000 live births when the national estimates for India was 572 per 100,000 live births. Likewise, the successive SRS estimates have suggested that the states of Uttar Pradesh, Rajasthan, Madhya Pradesh, Bihar and Assam in the year 1997 and 1998 have maternal mortality rates of over 400 per 100,000 live births when the national estimates for the same years were at 408 per 100,000 live births (Table I).

The states with high mortality rates have been indicated in bold in the above table. Also given are the indicators on how maternal care is provided in these states. For a variety of reasons, these states with high MMR also happen to be the ones with poor ante-natal care (less than 20% women getting the recommended antenatal care), less than or just about 20% of women getting their deliveries conducted in health institutions and a large proportion of deliveries still conducted by untrained individuals. The reasons for this are many. They may be either at the level of the community in terms of poor caring status when it comes to pregnant women or due to poorly developed infrastructure, under-staffed public health facility unable to provide the right type of care. The two tend to reinforce each other. Above all, it may be noted that these are the states with very high fertility rates and, therefore, account for greater number of deliveries and thus higher maternal mortality accounting for very high maternal mortality in India on an average.

The second relates to the causes of maternal mortality. The FOGSI study found the common causes to be anaemia, PET/eclampsia, sepsis, haemorrhage and abortion related in that order. These together contributed to over 80% of the deaths. The SRS has estimated the causes of death (estimated through verbal autopasy conducted by lay enumerators specially trained for the purpose) as being haemorrhage (29.6%), severe anaemia (19.0%), sepsis (16.1%), obstructed labour and ruptured uterus (9.5%), abortions (8.9%) and pre-eclampsia (8.3%). The recent National Family Health Survey has estimated that nearly 49.7% of pregnant women surveyed were having some form of anaemia or the other. There were 21.8% who had mild anaemia (Hb of 10 to 11 g%), 25.4% with moderate anaemia (7 to 10 g%) and 2.5% with severe anaemia. With such high levels of anaemia in the country, it can be said that most of the interventions to prevent maternal deaths have to occur immediately after the onset of the early symptoms such as bleeding during pregnancy, non-progression of labour, fever etc. We already know that the estimated average interval from onset to death for major obstetric complications is very short, meaning that interventions have to occur with a sense of urgency that is almost rare in our public health system, notably in the states where the maternal mortality rates are very high.

Mean Interval from onset to death for major obstetric complications*

Complication Hours Days
Haemmorrhage    
-Post Partum 2  
-Ante Partum 12  
Ruptured Uterus   1
Eclampsia   2
Obstructed Labour   3
Sepsis   6

*Deborah Maine in Safe Motherhood Programs: Options and Issues 11

There is as yet at the community level, no perception that any of these complications are serious and can result in death if not attended within the time indicated. Next, even where efforts are made to seek medical attention, the community lacks either the means or the knowledge on where to go for such emergencies. Not all health centers or hospitals are equipped to tackle emergencies in obstetrics. Even simple measures such as giving an injection of methylergometrine, starting intravenous fluids, antibiotics therapy or treatment of toxaemia of pregnancy are not available in most Health Centres particularly in the states where the MMR is high. Where they are available, the health professionals may not be available at the odd hours when these emergencies occur.

There are no short-cuts to developing the Emergency Obstetric Care (EOC) facilities in the states of Bihar, Uttar Pradesh, Madhya Pradesh, Assam and Rajasthan, if India has to successfully bring the MMR down to what is stated in the new Population Policy of India12. Development of the EOC facilities mean that hospitals with the minimal facilities such as anaesthesia, surgery and blood transfusion together with laboratory are identified, adequately staffed to provide 24 hour emergency services and the requisite training given to all staff of the hospital to respond in time of emergencies. This calls for not only an attitudinal change of the policy makers and health care professionals but also substantial investment in developing the secondary level hospitals in rural India of the Hindi heartland. Finally, any input of this nature will not be successful in reaching the desired results without the co-operation of the community. The community will need to be involved not only through educating them about the signs and symptoms of emergency but also to develop appropriate mechanisms for ensuring that women in distress get the quality care. Of course, these cannot happen in a short span of time. Collaboration with private hospitals and enlisting the support of institutions from the industry will be necessary to ensure that women are no longer condemned to death while giving life to a newborn.

References:

  1. National Health Policy, Ministry of Health and Family Welfare, Government of India, New Delhi,1982.
  2. Health for All, World Health Organisation, Geneva, 1977.
  3. Revised 1990 Estimates of Maternal Mortality, World Health Organisationand UNICEF, April 1996.
  4. Maternal Mortality in India, Project Report, Dr. Rohit V Bhat, Maternal Mortality Committee, Federation of Obstetric and Gynaecology Societies of India, 1992 94.
  5. National Plan of Action on Children, Department of Women and Child Development, Government of India, August, 1992.
  6. National Child Survival and Safe Motherhood Programme, Ministry of Health and Family Welfare, Government ofIndia, 1992.
  7. National Family Health Survey, International Institute for Population Sciences, Mumbai, 1992-93.
  8. MMR in 1997, Sample Registration System Bulletin, Registrar General of India, Ministry of Home Affairs, April, 1999.
  9. MMR in 1998, Sample Registration System Bulletin, Registrar General of India, Ministry of Home Affairs, April, 2000.
  10. National Family Health Survey, International Institute for Population Sciences, Mumbai, 1998-99.
  11. Safe Motherhood Programs: Options and Issues, Deborah Maine, Centre for Population and Family Health, School of Public Health, Columbia University, New York.
  12. Population Policy, Ministry of Health and Family Welfare, Government of India, 2000.
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