Maternal death is defined as death of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by pregnancy or its management. The maternal mortality ratio is maternal death per 100,000 live births in one year. Reliable estimates of maternal mortality in India are not available. WHO estimates show that out of the 529,000 maternal deaths globally each year, 136,000(25.7%) are contributed by India.
This is the highest burden for any single country. There are variations in MM by region and state. The indirect estimate done by Bhat (Maternal mortality in India: An update. Studies in Family planning, 2002) show that MMR is higher in eastern and central regions and is lower in north-western and southern region. Similar picture is also shown by data collected under Sample registration system by Registrar General of India in 1997.Socio-economic variations in MM are known but not well documented in India. Study of Bhat shows that generally MMR is more in scheduled caste and tribe community and those living in less developed villages. Variation with income is somewhat inconsistent with the expectation that the poor will have higher mortality. There are no precise estimates of MM it is difficult to say with certainty that maternal mortality has gone down over time. But data shown by various studies as those by Bhat show that there is a gradual decline in MMR.However direct measurement (RGI and NFHS) are inconsistent and do not show any decline.
NFHS shows that in urban areas the estimate of MMR (267) has gone down but in rural areas (619) it seems to have increased substantially even though it may not be statistically significantly different. The most common causes of maternal deaths are hemorrhage (ante partum or post partum), eclampsia, pre-eclampsia, infection, obstructed labor and complications of abortion; they are generally same throughout the world. The studies in India of causes of maternal mortality by and large show similar results. One difference is that the data on cause of maternal mortality from the Registrar General of India show large proportion of maternal deaths attributed to anemia which is not reported from other countries.
Causes of maternal mortality: India studies and global pattern (% of total deaths by causes)
|Source and location||Registrar General of India 1998||Bhatia data 84-85(Causes of mm in south India)||Kumar data 1986(MM enquiry in rural community of north India)||Maine Safe motherhood program)|
|Causes of death||National||Ananthpur district||Rural north India||Global pattern|
|Hypertensive disease of pregnancy||8.3||8.0||5.5||17|
|MMR per 100000 live birth||407||830||230|
In the 60s and 70s maternal health services under MCH focused on ante-natal care and high risk approach. It was thought that good antenatal care along with high risk approach will help in reducing maternal mortality. As traditional birth attendants were conducting many deliveries, it was thought that by training them MMR will decline.
But after several years of implementing these approaches it was realized in mid-80s that MM was still very high in many developing countries including India. A re-look at the causes of maternal death and the socio-medical factors contributing to maternal death brought out a completely new understanding of how to prevent maternal mortaility.
This showed that
It is not possible to predict which mother will develop complications and hence the high-risk approach does not help much.
Most complications cannot be prevented by good antenatal care. Hence ANC alone cannot prevent maternal mortality.
If obstetric complications are handled effectively the mortality could be substantially reduced.
It was also shown that once major obstetric complications which can cause death develop, even a trained TBA or a nurse cannot do much at home as many of these complications require surgical interventions, injections of antibiotic, blood transfusion and other aggressive treatment.
Cost-effective approach to reducing maternal mortality was by ensuring high quality emergency obstetric care (EmOC) to mothers who develop complications during delivery.
It was proposed that development of First Referral Units where emergency obstetric care can be provided would be required to reduce maternal mortality. It was also argued that development of FRUs was the most cost effective way of reducing maternal mortality. This approach was also accepted by many international donors and became the main strategy for many country programs for preventing maternal mortality.
The government of India has been time and again making policy and programmatic statements and setting goals of reducing MM.
Major policy and program goals in MM
|1983||Health policy statement by Govt of India||MMR reduction by 200-300 by 1990 and below 200 by the year 2000|
|2000||National population policy||MMR reduction to less than 100 by 2010|
|2002||National health policy||MMR reduction to less than 100 by 2010|
|2002-007||Tenth Five year plan||MMR reduction to less than 200 by 2007|
In spite of these clear policy intentions the progress on the ground has been very slow. Review of 8th and 9th Five year plan shows that there was hardly any description of strategies or achievements related to maternal care and maternal mortality reduction goals.
To ensure that safe motherhood agenda does not get neglected it is important to have high priority, clear objectives and effective long-term strategy in RCH II programme which plans to cover wider spectrum of services. Specific long- term objectives should be set up such as reducing unmet need for EmOC and increase in coverage of skilled attendance. Such clear objectives should be followed by effective long term strategy to increase access, utilization and quality of EmOC and maternity services. There should be detailed implementation guidelines and plans and powers to local managers who can make changes in order to keep the services running without interruption.
The project development process should ensure that all the critical inputs such as staff, drugs and equipment are provided at strategically selected locations for addressing the objectives. It would also ensure that all the inputs are coordinated. The supervision and monitoring should assess the functioning of the facility, their output and quality. The monitoring should be based on appropriate indicators such as the UN process indicators for EmOC.A national maternal mortality study should be carried out every 10 years to ensure that there are reliable data to indicate progress towards ultimate goal of safe motherhood.
As this program has substantial technical components as compared to other preventive programmes, hence the government needs high quality technical support by public health experts, obstetricians, midwives and management experts. There is also an urgent need to expand the size of the technical staff for maternal health in the ministry at state and central levels which is extremely small. Long term skills development should be taken up for medical officers and nurses to provide basic EmOC services even in the absence of an obstetrician. Good performance should be recognized and rewarded and wanting performance should be duly corrected.