The health and education of all human beings living in a country are its most precious assets. In India, education has been a fundamental right of human beings, and with the adoption of the National Health Policy Statement, the 1978 “Health for All Declaration” became the guiding concept for Government of India’s policy. The survival and well-being of mothers are most important for the country’s future generations.
The Maternal Mortality Rate (MMR) is one of the important indicators of quality of health services provided to pregnant women (see Box). Despite good progress especially since 2005, still estimated 47,000 mothers continue to die annually due to causes related to pregnancy, child birth and post-partum period. The major medical causes of these deaths are haemorrhage, sepsis, abortion, hypertensive disorders, obstructed labour and anaemia. Besides, a number of determinants like illiteracy, low socio-economic status, early age of marriage, low empowerment of women and traditional preference for home delivery are responsible for maternal deaths. A recent review of maternal deaths suggests that about 26 per cent of maternal deaths occurred at home, 25 per cent in transit, and 48 per cent at the health facilities.
The Maternal Mortality Rate
The number of women who die from any cause related to pregnancy (excluding accidental or incidental causes), during pregnancy and child birth or within 42 days of treatment of pregnancy, irrespective of the duration and site of pregnancy, per 100,000 live births is called the Maternal Mortality Rate (MMR). The causes attributed for such deaths include general health status, educational level and physical movement during pregnancy and child birth. Most maternal deaths are avoidable and can be prevented through appropriate health care, managing complications during pregnancy and deliveries. Improved access to antenatal care during pregnancy, skilled care during child birth and in the weeks after child birth reduces maternal deaths. As the reduction in MMR is highly influenced by various healthcare factors, it is also used as the measure of the quality of a health care system.
India on an international scale
In 1990, MMR in India was very high, at 600, which meant approximately 150,000 women dying each year as compared to 400 MMR globally, indicating 540,000 women dying each year. At that time, India contributed 27.77 per cent of the global maternal deaths. In 2010, global MMR was 210, against 178 in India in 2011. India is now contributing only 16 per cent of global maternal deaths. Globally, there was a decline of 47 per cent between 1990 and 2010, as against a decline of 70 per cent between 1990 and 2011 in India, which showed an annual rate of decline of 5.6 per cent as compared to 2.4 per cent at global level.
Programmes and policies to strengthen women’s health
Today, the maternal mortality rate in India is at 178. The highest rates of decline are evident from the years 2004-06 on. The following programmes and measures were above all responsible for this improvement:
Maternal Mortality Rate during 1990-01 to 2010-12
Figures in parentheses indicate the total number of deaths (MMR is estimated periodically by pooling three years of data to yield reliable results).
Rural areas need special attention
According to the scientific journal The Lancet, a quarter of all maternal deaths in India are caused by anaemia, and nearly a fifth by calcium deficiency, both of which lead to frequently fatal complications at childbirth. The problem is especially acute in rural areas (see Box at end of article). Therefore, intervention programmes to provide iron supplements to women should be scaled up in rural areas and effectively implemented.
In addition, the awareness campaign for supplemental nutrition among rural women has to be intensified to remove superstition and rumour about its effects on unborn children. The chief task would be to improve universal access to nutrients through a basket of commodities (including pulses, fruits and vegetables) that can be supplied through a variety of channels. Clearly, the Public Distribution System and community-run not-for-profit institutions would form the backbone of such an effort. What is often grossly neglected in practice is the importance of early childhood nutrition (crucially, the first 1,000 days) for life-long health. The Government should amend its National Food Security Act appropriately to provide universal access to nutritious food.
Measures to be implemented
The NRHM – now being a part of the National Health Mission – should not dilute the focused attention in rural areas to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups, among them women. The following measures should be implemented to strengthen maternal health in rural areas:
The rural-urban divide
The under 5 mortality rate [U5MR] is the number of children dying before reaching the age of five years per 1,000 live births in a specified year. Rural areas have registered high rates compared to urban areas. In 2013, the U5MR in rural areas was 55 against 29 in urban areas. During 2009–13, the urban U5MR declined from 41 to 29 as compared to from 71 to 55 in rural areas. U5MR in rural areas continued to increase from 73.2 per cent in 2009 to 89.6 per cent in 2013 over that in urban areas.
IMR is the number of deaths in children under one year of age per 1,000 live births. The causes attributed to IMR include the health of mothers and the extent of pre/postnatal care, general living conditions, rates of illness, quality of the environment, among others. Thus, IMR is a very important indicator of health for children as well as for the population as a whole. Rural and urban areas have witnessed significant decline in IMR for several years. However, IMR in rural areas continues to be at a much higher level than urban IMR, exhibiting a rural-urban gap (44-27) in 2013. IMR in rural areas marginally declined by 63 per cent in 2013 from 70 per cent in 1990 over that in urban areas.
The Coverage Evaluation Survey of the UNICEF and the Government of India shows that India achieved 74 per cent of one-year-old children immunised against measles in 2009. Although there has been substantial improvement in the coverage since 1992/93, when it was 42 per cent, at this rate of coverage, India was likely to achieve 89 per cent coverage by 2015, falling short of universal coverage. There is a rural-urban gap in the coverage of immunisation against measles as in rural areas coverage, was 72 per cent against 78 per cent in urban areas. The extent of coverage is highly correlated to mother’s level of education.
For reducing MMR and IMR, it is necessary that all births are attended by skilled health personnel as timely treatment by professional can make the difference between life and death. Skilled health personnel include only those who are properly trained and who have proper equipment and drugs but not traditional birth attendants, even if they have received a short training course. Skilled and trained health personnel provide care and counsel women during pregnancies and the labour and postpartum periods. They facilitate safe deliveries and care for newborns. The goal is 100 per cent coverage of live births by skilled health personnel. In 2013, at national level, skilled health personnel attended 84.1 per cent live births in rural areas and 98.2 per cent urban areas. There are States which are far behind 100 per cent coverage and exhibit a significant rural-urban gap in coverage.
Source : Annual Reports (2010-15) of Ministry of Women & Child Development, Government of India
Dr Amrit Patel, Consultant, Ahmedabad/India