Reducing maternal mortality: Miles to go
Reducing maternal mortality has been an area of concern for governments across the globe. India has affirmed its commitment to reducing maternal mortality through various state policies and by adhering to international development targets like Millennium Development Goals (MDG). Maternal mortality ratio (MMR) figures recently released by the Sample Registration System (SRS) shows that India has failed to achieve the MDG target of reducing MMR by a margin of 21 points from the present 130. India has also failed to reduce the MMR to 100 as mandated by the National Health Mission (2012-17).
India was nevertheless praised by the WHO and Unicef for having reduced the MMR from 167 to 130 between 2011-13 and 2014-16. Both WHO and Unicef acknowledged that NHM (including the National Rural Health Mission or NRHM) has been a game-changer, increasing access to quality maternal health services.
However, data from National Family Health Survey-4 (NFHS-4) and the Performance Audit Report of NRHM 2017 by the Comptroller and Auditor General of India tell a different story, and explain the possible reasons for the failure to achieve the MDG and NHM targets.
Ante-natal care, postnatal care and delivery at a health facility reduce health risks for mothers and their babies by ensuring monitoring of pregnancies and screening for complications, and are instrumental in reducing maternal deaths.
One of the major interventions under NRHM is to register all pregnant women within 12 weeks of pregnancy and provide services such as four antenatal check-ups (ANC), 100 iron folic acid (IFA) tablets, and two doses of tetanus toxoid (TT) vaccine, proper diet and vitamin supplements. The WHO recommends at least four visits to an ANC centre.
Data from NFHS-4 show that just 51 per cent of pregnant women in India are able to visit an ANC centre at least four times. Similarly, just 21 per cent of pregnant women receive all types of ANC services. At the state level, a mere 3.3 per cent of pregnant women in Bihar and 5.1 per cent in UP received all recommended types of antenatal care.
As per the guidelines of Reproductive and Child Health-II, the intrapartum period (defined as labour, delivery and the following 24 hours) is a critical time for recognising and responding to obstetric complications and seeking emergency care to prevent maternal deaths.
The 2017 CAG Report on NRHM noted that more than 40 per cent of newborns were not visited by a health worker within 24 hours of home delivery in Jharkhand, Madhya Pradesh, Manipur, Mizoram, Odisha, Rajasthan, Sikkim and Uttar Pradesh.
There has been a significant increase in the percentage of institutional births in India, from 38.7 per cent in 2005-06 to 78.9 per cent in 2015-16. According to NFHS-4, of the 78.9 per cent institutional births in 2015-16, just 52.1 per cent happened in a public health facility and 26.3 per cent in a private health facility. The average out-of-pocket cost paid for delivery in a public health facility was ~3,198; in a private health facility it was ~16,522.
To encourage institutional delivery, the Janani Suraksha Yojana (JSY) was launched to provide all pregnant women with cash assistance ranging from ~500 to ~1400. The cash assistance was to be provided to the mother in one go at the health centre immediately on arrival and registration for delivery.
The CAG Report noted that in six states (Himachal Pradesh, Karnataka, Punjab, Rajasthan, Sikkim, and West Bengal), 40 per cent or more of the beneficiaries did not receive any cash assistance under JSY. In another six (Assam, Haryana, Jammu and Kashmir, Manipur, Odisha and Uttarakhand), cases of delayed payment of cash assistance for the period 2011-16, ranging from 11 to 1,366 days, were observed. In Bihar, 12,925 cheques for a total value of ~17.3 million were not delivered to beneficiaries.
According to the CAG report, at the all-India level, there is a shortfall of 38 per cent in community health centres, 28 per cent in primary health centres and 24 per cent in sub-centres. The percentage shortfall in the availability of these facilities was more than 50 per cent in Bihar, Jharkhand, Sikkim, Uttarakhand and West Bengal. Similarly, there is a huge shortage of health personnel in rural health facilities. About 49 per cent of the positions for doctors/specialists and 35 per cent of the positions of staff nurses and paramedical staff are vacant in different rural health facilities.
Clearly, there are serious issues in the access and availability of maternal health care services in India. Even the budgetary allocation to the NRHM, as a share of total health expenditure, declined from 52 per cent in 2015-16 to 44 per cent in 2018-19. After termination of the MDG framework in 2015, India adopted the Sustainable Development Goals-2030 framework and resolved to reduce the MMR to less than 70 by 2030. This would require ensuring universal access to quality sexual and reproductive health care services, improving the implementation of schemes such as NRHM and JSY, and bringing parity between urban and rural areas in access to health services.
Recently released figures show that India has failed to achieve the Millennium Development Goals target of reducing the maternal mortality ratio by a margin of 21 points from the present 130