NEW DELHI: India’s maternal mortality ratio (MMR), a key health system indicator, dropped to 113 in the 2016-18 period from 122 in 2015-17, according to the latest data released by the office of the registrar general of India. One of the UN’s sustainable development goals is to reduce MMR, defined as the number of maternal deaths during a given time period per 100,000 live births, to less than 70.
India’s MMR used to be about 556 in 1990 and 254 in 2004-06. Assam continues to be the state with the highest MMR over the last three sample surveys conducted, followed by Uttar Pradesh and Madhya Pradesh, an order unchanged since the 2014-16 survey. Over the same period, Kerala, Maharashtra and Tamil Nadu, in that order, continue to have the lowest MMR.
While Maharashtra and Tamil Nadu have been steadily reducing their MMR, Kerala’s MMR went up slightly from 42 in the last survey to 43, though it remained the lowest in the country. Among some of the other states which saw an increase in MMR, the most alarming increase was in Chhattisgarh, where it went from 141 in the 2015-17 survey to 159 in the current one. Uttarakhand, too, saw an increase from 89 to 99, Punjab from 122 to 129, and West Bengal from 94 to 98.
The main causes for maternal mortality are severe bleeding, mostly after childbirth, infection following childbirth, high blood pressure during pregnancy causing seizures or complications during childbirth, and unsafe abortions. Thus, it was believed that these causes could be addressed if deliveries happened in health institutions where trained health personnel would be available, resulting in a huge government push to increase institutional deliveries, which were just 43% in 2004. By 2018, institutional deliveries constituted 83% of all childbirths in India.
While this push seemed to have paid off initially in bringing down MMR substantially, the increase in institutional deliveries in many states is no more showing a corresponding decrease in maternal mortality. In Assam, for instance, institutional deliveries are almost 83%, much higher than say Bihar with just 70% or Jharkhand with just 61.7%. Yet, MMR in Assam is 215, while it is 149 in Bihar and just 71 in Jharkhand. In Karnataka, despite institutional deliveries being as high as 97.6%, its MMR of 92 is higher than that of Haryana (91) or Telangana (63) where institutional deliveries constitute only 86% and 94%, respectively, of the total.
Public health experts have published several papers on the poor quality of healthcare offered in many of these institutions, both public and private, towards which women have been pushed — through cash incentives for health workers and for the pregnant women themselves to opt for institutional delivery. Poor hygiene in health facilities is one major reason for infections post-childbirth. Excessive bleeding, which accounts for roughly 30% of maternal deaths in India, could be due to hospitals, especially rural ones, not having any blood banks.
Many developed countries have successfully brought down MMR to single digits. Italy, Greece and Spain, with an MMR of 2, 3 and 4, respectively, have among the lowest, while it is 7 in both Germany and the UK, 10 in Canada and 19 in the US. Most of India’s neighbours — Nepal (186), Bangladesh (173) and Pakistan (140) — have a higher MMR. However, China and Sri Lanka are way ahead with MMR of 29 and 36, respectively.


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