This document provides an overview of maternal mortality in India. It begins with definitions and statistical measures related to maternal mortality. It then discusses trends in maternal mortality worldwide and in India, highlighting that India accounts for 19% of global maternal deaths. The main causes of maternal death in India are also reviewed. National programs and policies aimed at reducing maternal mortality are outlined. Several constraints to reducing maternal mortality are then described at various levels of the health system. Examples from other countries are provided to illustrate how some constraints have been addressed successfully.

1. Critical Review - MMR
Dr Manisha
Junior Resident
Department of Community Medicine
PGIMS,Rohtak

2. Content
• Introduction – definitions & statistical measures
• Trends of MMR : World
• Trends of MMR : India
• Main Causes & Interventions to prevent
• National programmes & policies
• Constraints
• Examples

3. Friday, October 12, 2012

5. • India has the highest
burden of maternal
deaths in the world –
56,000 per year--19 %
of total worldwide
• Actual Situation is worse --
maternal deaths--in remote
rural areas – remains under-
reported.

6. Definitions related to maternal
death in ICD-10
1. Maternal death
Alternative definitions:
2. Pregnancy-related death
3. Late maternal death
The death of a woman while pregnant
or within 42 days of termination of
pregnancy, irrespective of the duration
and site of the pregnancy, from any
cause related to or aggravated by the
pregnancy or its management but not
from accidental or incidental causes.
This definition allows identification of maternal
deaths, based on their causes, as either direct or
indirect
Direct : resulting from obstetric complications of the pregnant state
(pregnancy, delivery and postpartum), interventions, omissions, incorrect
treatment, or a chain of events resulting from any of the above.
e.g. obstetric hemorrhage or hypertensive disorders in pregnancy, or
those due to complications of anaesthesia or caesarean section
Indirect: resulting from previously existing diseases, or from
diseases that developed during pregnancy and that were not
due to direct obstetric causes but aggravated by physiological
effects of pregnancy.
e.g. deaths due to aggravation of an existing cardiac or renal
disease
The death of a woman from direct or indirect obstetric causes, more
than 42 days but less than one year after termination of pregnancy.
Complications of pregnancy or childbirth can lead to death beyond the
6 weeks’ postpartum period
The death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the cause of death.
Useful in settings where accurate information about causes
of deaths based on medical certificates is unavailable.
e.g. in population-based surveys

7. Statistical measures
• Maternal mortality is the combination of two factors:
(i) the risk of death in a single pregnancy or a single live
birth;
(ii) the fertility level, that is, the number of pregnancies or
births that are experienced by women of reproductive age.
• Measures are
1) Maternal mortality ratio
2) Maternal mortality rate
3) Adult lifetime risk of maternal death
4) The proportion maternal death among deaths of
females of reproductive age (PMDF)

8. TRENDS IN WORLD

9. Maternal Mortality: A Global Tragedy
• Annually, 287,000 women
die of pregnancy related
complications
• 99% in developing
world
• ~1% in developed
countries
Every minute one
Maternal Death occur
• 10 to 20 million women
develop physical or mental
disabilities every year as a
result of complicated
pregnancies and deliveries.

10. World : 2010
Estimated maternal deaths : 287,000 (decline of 47% from levels in 1990)
Global MMR : 210 (in 1990 : 400) (source:Trends in maternal mortality:1990 to 2010 WHO, UNICEF,
UNFPA and The World Bank estimates)
 Highest MMR -- Sub-Saharan
Africa (500) .
Lowest MMR-Eastern Asia (37)
 Sub-Saharan Africa (56%) and
Southern Asia (29%)
accounted for 85% of the
global burden .
2 countries account
for 1/3 of global
maternal deaths:
India -- 19% (highest-
56000)
Nigeria -- 14% .
In developing regions
(240) 15 times higher
than in developed
regions (16).
low
moderate
high
Extremely high

11. 47%
54%
42%
66%
40%
42%
66%

12. Millennium Development
Goal 5:Improve maternal
health
Targets Indicators
5.A Reduce by three quarters,
between 1990 and 2015, the maternal
mortality ratio
5.1 Maternal mortality ratio
5.2 Proportion of births attended by
skilled health personnel
5.B Achieve, by 2015, universal
access to
reproductive health
5.3 Contraceptive prevalence rate
5.4 Adolescent birth rate
5.5 Antenatal care coverage (at least
one
visit and at least four visits)
5.6 Unmet need for family planning

13. Maternal Mortality Estimation Inter-Agency
Group (MMEIG)-MDG estimates
• Categories : To measure progress, countries with MMR
≥100 in 1990,
• “on track” : if the annual percentage decline between
1990 and 2008 is 5.5% or more :: 9 countries
• “making progress” : annual decline between 2% and
5.5%, :: 50 countries {INDIA– 5.2}
• “insufficient progress” : annual decline of less than 2% . ::
14 countries
• “no progress” : countries with rising MMR . :: 11 countries
10 countries that already
achieved MDG 5 by 2010 : Estonia (95%),
Maldives (93%), Belarus (88%), Romania
(84%),
Bhutan (82%), Equatorial Guinea (81%),
Islamic Republic of Iran (81%), Lithuania
(78%),
Nepal (78%) and Viet Nam (76%).

14. TRENDS IN INDIA

15. Projected value-139 by 2015
8%
16% during
2003-06
17% during
2006-09
Source – SRS(2007-09)
153
HARYANA
Only 7 States-Andhra Pradesh, Goa,
Karnataka, Kerala, Punjab, Sikkim and
Tamil Nadu -likely to achieve or close by
2015.WHO estimates
437
India :

16. Major policy and program goals in MM
Year Document Goals
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
2002-2007 Tenth Five year plan
MMR reduction to less than
200 by 2007

17. CAUSES &
INTERVENTIONS

18. Maternal Mortality-Magnitude and Causes
About 28 million pregnancies and 56,000 maternal deaths per
year in India

20. 20
Maternal deaths averted throughMaternal deaths averted through
access to servicesaccess to services (World(World Bank, 2004)Bank, 2004)

21. But WHY Do These Women Die?
Three-Hurdle Race against Death
• Delay in Decision to Seek Care
• Lack of understanding of complications
• Acceptance of maternal death
• Low status of women
• Socio-cultural barriers to seeking care
• Delay in Reaching Care
• Mountains, islands, rivers — poor organization
• Delay in Receiving Care
• Supplies, personnel
• Poorly trained personnel with punitive attitude
• Finances
Three Delays Model

22. PROGRAMMES &
POLICIES

23. MCH care in India
• 1880-- Establishment of training of dais in Amritsar
• 1902--Passing of first Midwifery Act in London to promote
safe delivery.
• 1931-32--Setting up of advisory committee on maternal
mortality. They scrutinised causes leading to maternal
deaths in hospitals and recommending actions.
• 1946--Bhore committee- Primary health centres came up
in 1952&MCH centres became its integral part by 1956.
• 1992--Child Survival & Safe Motherhood programme,
FRU - EmOC
• 1997--RCH
• 2005-- RCH II under National Rural Health Mission
(NRHM)

24. RCH
NRHM
ICDS
JSY
JSSK
Ladli
Rashtriya Swasthya
Bima Yojana
Balika Samriddhi Yojna
Janani Suvidha Yojna
Indira Gandhi Matritva
Sahyog Yojana
Rajiv Gandhi National
Creche Scheme
Kishori Shakti Yojana
Delivery Hut Schme
Vikalp Yojana
Jachcha Bachcha
Scheme
WOMEN’S HEALTH- govt. policies

25. INDIA MDG – MATERNAL HEALTH
SERVICES-Good quality services are not universally
available and accessible
0
10
20
30
40
50
60
70
80
34
41
62
27
17
42
48
65
30
16
47
56
74
37
13 1993
1999
2006
MILLENNIUM DEVELOPMENT GOALS
INDIA COUNTRY REPORT 2011
Still more gaps left to
be bridged for safer
motherhood…

26. CONSTRAINTS ….

27. Constraints to Improving Access,
by Level
• Community and household level-
1.lack of demand for effective interventions due to
knowledge,perceptions,culture or language
2. barrier to the use of effective
interventions(physical,financial,social)
• Health services delivery level:
1.Shortages and inadequate distribution of appropriately
qualified staff
2.Weak information system,technical guidance,program
management or supervision
3.Inadequate drug or other medical supplies
4.Lack of equipment,infrastructure or referral system

28. • Health sector policy and strategic management level-
1.weak or overly centralized planning and management
system
2.insufficient use of evidence in decision making
3.weak drug policy or drug supply system
4.lack of interministerial and intersector action
5. Weak partnerships for health between government,
civil society & private sector
Constraints to Improving Access,
by Level

29. • Environmental and contextual characteristics –
• Government and overall policy framework
1.corruption,weak government, weak rule of law
2.low priority attached to social sector-
• Physical environment unfavourable to service delivery
• Global level
1.lack of reliable estimates
2.number of global initiatives and misalignment of
reforms
2.reliance on project funding modes and limited use of
country’s financial management system
Constraints to Improving Access,
by Level

30. Lack of reliable estimates of maternal
mortality
• Without it, the impact of safe motherhood programmes
remains unknown.
• Sweden, Sri Lanka, and Malaysia established robust vital
registration systems at early stages of their battle against
maternal mortality.
• Information on the levels, causes, and patterns of
maternal mortality in India is, at best, incomplete and
unsatisfactory
1. Civil registration system - Ideal
2.Household surveys ,Demographic and Health Surveys
(DHS) and Multiple Indicator Cluster Surveys (MICS)
3.Census
4. Reproductive-age mortality studies (RAMOS)
5. Verbal autopsy

31. Lack of demand for effective
interventions & financial barrier
• Despite guarantee of free health services from the public
health system, households contribute 71.13 % of total
health expenditure for availing health care services from
different institutions (NHA-2004-05)
• Among mothers in lowest wealth quintile households, 59
% received any antenatal care & 23 % received check-
ups from doctor; corresponding figures -97 % & 86 % for
highest quintile households

32. Demand-side incentives - conditional cash transfers
(CCTs)
India JSY- 2005 In just two years, enrollment in
JSY increased 10-fold, from a
low of 0.7 million JSY
beneficiaries in 2005/06 to 7.3
million beneficiaries in 2007/08.
Latin
America
Since 1997,encouraging poor
mothers to seek preventive
health services and attend
health education talks
Sudden and dramatic
increases in service utilization
The health system needs to be sufficiently geared up .
Otherwise the poor quality of services received will result in clients
having a low opinion of the services and ultimately reduce demand
for services at these facilities.
Lack of demand for effective
interventions & financial barrier

33. Shortages and inadequate distribution
of appropriately qualified staff
• A dearth of available skilled manpower and
mismanagement of available human resources, especially
in the rural public-health system inspite of :
by increasing recruitment
adding more tasks to the workload of existing staff or task
shifting (e.g. ANM), or
contracting with the private sector

34. 0
0.5
1
1.5
2
2.5
Number of PHCs with no Staff Nurse
0
0.5
1
1.5
2
2.5
3
3.5
Number of PHCs with no MOs
NO.OFPHCs
NO.OFPHCs

35. 0
1
2
3
4
5 Number of PHCs with LMO
0
1
2
3
4
5
SUB-DIVISIONAL HOSPITALS
GYNAECOLOGISTS PAEDIATRICIANS ANAESTHETISTS

36. KNOWLEDGE & SKILLS
PERCENT SN WHO
KNEW
1. Identification of high risk pregnancies 51.5%
2. Identification of high risk newborn 46.6%
3. Blood pressure measuring 55.3%
4. Abdominal examination 48.5%
5. FHS hearing ability 52%
6. Asepsis maintainance during delivery 48.5%
7. Filling the partograph 28.6%
8. PPH management 49.6%
9. Mucous extractor use 48.1%
10. Ambu-bag use 39.7%
11. Radiant warmer use 22.5%

37. Maternal death audits and reviews of maternal deaths
• allows lessons learned to be utilized in prevention in future
• If in all health facilities - the total number can be calculated
Botswana
>98 %
deliveries
with skilled
health
personnel
Maternal Mortality Monitoring
System in 2005
• midnight census of admissions
and deaths at all health facilities;
• birth notification forms for non-
institutional deliveries
• completion of maternal death
notification forms after a maternal
death audit
More accurate national
estimates of maternal
mortality
(Source: Republic of
Botswana et al. 2006)
India HMIS and civil registration systems
???
Weak information systems

38. Rwanda:
after the war,
user fees were
instituted--
dramatic decline
in the use of
health services.
In 1998
• use of skilled health personnel
for delivery with performance-
based schemes
• free delivery care for regular
antenatal care beneficiaries.
institutional deliveries
increased from 12.2
percent in 2001 to 23.1
percent in 2004, in
contrast to 6.7 percent in
2001 to 9.7 percent in
2004 in the non-
participating provinces
(Source: Rusa et al. 2009)
India Jachha bachha scheme???
Accurate data is needed to verify the outcomes of performance-
based financing approaches. HMIS should be strengthened to
provide reliable routine data with periodic verification.
Lack of incentives to provide
quality health services
• An extreme example is the ANM or doctor, who lives in a
remote village and provides 24-hour services, gets the
same salary and benefits as an ANM or a doctor who
lives in a city, and commutes irregularly to a rural health
centre for a few hours a day where s/he is posted.

39. Lack of equipment, infrastructure
• Poor & inadequate drug supply
• Poor condition of equipments
• Lack of leadership in taking initiative at lower levels –
district, block level
• Policy on upgrading of infrastructure & equipments – does
not cover all range of issues , centrally managed, takes
long time in processing

40. Privacy assured during the
stay at PHC
X-Ray Unit in PHC
Baby warmers at PHC
Clean and Neat environment
RO , Solar water
heater
Communication

41. Lack of referral system
• FRUs
• Secondary referral system-DH,SDH in poor condition
• Patient load directly to trtiary level—poor quality care due
to patient and health care giver disproportion
Djibouti
(high urban
population
>80% in a
small
geographical
area,
In 2002,to reduce load on
referral national hospitals
• trained health personnel to
better handle emergency
obstetric complications;
• renovated/equipped the
hospital;
• strengthened the capacity of
the secondary level health
facilities (e.g., renovated
operating rooms, radios, and
ambulances)
percentage of births in
health facilities had,
remarkably, increased
from 40 percent in 2002
to 93 percent in 2006
(Source: World Bank,
reporting background
for Health Sector
Development Program
Project, Djibouti, Project
P071062.)

42. Weak partnerships for health between
government, civil society & private sector
Public private parternership
Honduras collaboration with private providers
to set up 13 birthing centers in
remote areas known for high
maternal mortality.
MMR ↓ from 182 to 108
Between 1980 and 1997
(Source: Koblinsky 2003)
Cuba Maternity waiting homes MMR ↓ from 118 to 31
Between 1963 and 1984
(Source: Koblinsky 2003)
Geographical areas or marginalized populations may
remain outside the reach of the public sector---
strategic partnerships .

43. Gujrat’s initiatives to reduce MMR
The Chiranjeevi Yojna (CY)
• launched in five poor districts in 2005 and since 2007 it
has been extended to entire Gujarat
• acute shortage of gynecologists in public health facilities
(only 7 against 273 CHC positions) so,GoG decided to
enlist their support from private
• Aim to remove the financial barrier to access of qualified
health care facility in vicinity.
• The cost will be borne by GoG Moreover Rs. 200 for
transport and Rs. 50 for accompanying person- A bridge
between private sector and the poor
• Qualified EPPs are paid Rs. 1,79,000 for a bunch of 100
deliveries including CS.

45. The Chiranjeevi Yojna (CY) - pitfalls
• Out of more than 200 gynecologist in Surat district, only
56 were registered for CY. Most of them located in Surat
city and remaining in peri urban area. None in remote
rural areas.
• Even out of registered 56, very few have been active and
conducting deliveries under the scheme,
• Some EPPs joined CY in hope that they will get
license/certificate for MTP by joining hands with
government.
• some EPPs taking only “safe” cases and diverting
complicated cases to public hospitals. In this case,the
whole purpose of the scheme is defeated .

46. • BPL card is required to become beneficiary of the scheme
but migrants don’t have documentary evidences and
therefore are left out of the scheme.
• Aanganwadi workers are the links between poor HHs and
EPPs but sometime the trust is broken as EPPs demand
money.
The Chiranjeevi Yojna (CY)

47. Lack of intersectoral coordination
Improvements in non-health sectors also have
influence on maternal health outcomes.
Malaysia In 1950s--multisectoral approach
 rural development including
• expansion of rural health
services,
• improving basic education and
female education,
• improving sanitation and water
supply,
• extending road networks in rural
areas.
 specific health interventions
such as professional midwifery
MMR ↓ from 534 to 19
Between 1950 and 1997
(Source: Padmanathan et al.
2003)
Integrated rural development together with key maternal
health interventions is the long term solution.
FACTORS OUTSIDE HEALTH SECTOR
Poor maternal nutrition
• Short spacing
• Early age at marriage
• Low levels of education in women
• Skewed gender relations
• Social position of women,family

48. EXAMPLE…

49. Tamil Nadu’s initiatives to reduce MMR
• 3 staff nurses in each
PHC -SBA skills trained.
• Filling vacancies of MOs
and equipping the PHCs
to provide BEmONC
services.
• Untied funds and Patient
Welfare Society funds
• Innovative IEC
techniquesImproved
Utilization Of
PHCs
• Hiring private anaesthetists
and obstetricians to carry out
caesarian operations
• Training MBBS doctors in
short term course in Life
Saving Anaesthesia Skills and
Emergency Obstetric Care.
• Emergency Referral Services
(Toll free no 108) introduced
Making
Emergency
Obstetric
Care
available

50. Melakkal PHC, Madurai HUD
Old Building
New Building
Tamil Nadu’s initiatives to reduce MMR

51. MMR
YEAR
110
127
126
114
123 126 133
145
123 114
109
94 95
91
79
0
20
40
60
80
100
120
140
160
Source DPH & PM
Before RCH RCH NRHM
AMTSL,
LSAS
training,
Hiring of
Specialists
Blood
storage
facility,
AN
protocol,
etc
EMRI
TREND MATERNAL MORTALITY---
TAMIL NADU

52. Interventions taken to reduce major
cause of maternal death
• AMTSL training for the whole state
• Blood storage centres and logistics of
how to use them in resource poor
settings
Haemorrhage
• Retraining to all VHNs in ante natal care
protocols and skills including basic BP
measurement
• Use of electronic BP apparatus
• Calcium supplementation for antenatal women
PIH
• Post natal care visits- emphasis of danger signs
in home based care training
• IEC/ BCC messages on danger signs
• Infection management practices in labour
rooms and post natal wards
Sepsis

53. Interventions taken to reduce major
cause of maternal death
• Training on use of partogram
• Emphasis on prompt referral
• District level quality control circles --
obstetricians and nurse trainers
Obstructed/
prolonged
labour
• Use of iron sucrose for severe anaemia
• Mandatory deworming
• Supplementation with Vit C and B-12
• Ensuring proper measurement of Hb levels
• Adolescent Anaemia Control programme
Anaemia
• Pregnancy cohort monitoring
• Verbal community death autopsy by the district
collector
• Focus higher order births- strong IUD campaign for
those unwilling to accept sterilization
• Policy for safe abortion and ensuring availability of
MVA services at least at the block level.
Others

54. THE SRI LANKA STORY-
A low-income country which has
successfully REDUCED MATERNAL
MORTALITY

55. Maternal Mortality Reduction
Sri Lanka 1940–1985
0
200
400
600
800
1000
1200
1400
1600
1800
1940–45 1950–55 1960–65 1970–75 1980–85
MaternalDeathsper100000livebirths
56
85%birthsattended
bytrainedpersonnel

56. • • A vast network of health infrastructure extending into
rural areas by the 1950s to make health services more
accessible.
• Blood transfusion services.
• Free Services .
• Training of Large cadres of professional midwives - both
at the health facilities & in communities .
• Additionally, midwives visited pregnant women at home
and encouraged them to seek antenatal care and
assistance during delivery.
Sri Lanka ’s initiatives to reduce MMR

57. • Family planning was integrated into maternal and child
health services and offered as part of the basic package
of services.
• A strong referral system ensured timely access to basic
and comprehensive emergency obstetric and newborn
care (EmONC) when necessary, backed by the availability
of ambulances and telephones.
• Given that public expenditure on health care was low (on
average less than 2 percent of GDP) during the 1950-
1999 period, this reduction cannot be attributed to a huge
investment of funds.
Sri Lanka ’s initiatives to reduce MMR

58. Ultimate aim for women health
LIFE CYCLE APPROACH
HEALTHY MOTHER
HEALTHY CHILD
HEALTHY
ADOLESCENT
HEALTHY
REPRODUCTIVE
YEARS
CYCLECONTINUESINTO
NEXTGENERATION

59. Conclusion
• Long-term sustained policy and financial commitment
to improve maternal health outcomes
• Strengthening health systems to effectively deliver
the Essential Package
MCH interventions must be integrated into the larger
health system. Not be a stand-alone program
Ensuring Adequate available skilled health personnel in
basic and comprehensive EmONC - doctors,
midwives,nurses with midwifery skills, and anesthetists.
Staff trained in referral protocols, esp. outreach staff.
A strong monitoring system -(i) to respond effectively to
specific implementation challenges; and (ii) to enhance
quality of care .
Known package of essential
interventions .
The challenge
To deliver this package at a
sufficient scale and with
sufficient quality to have a
significant impact.

60. References
• MILLENNIUM DEVELOPMENT GOALS .INDIA
COUNTRY REPORT 2011..Central Statistical
Organization, Ministry of Statistics and Programme
Implementation, Government of India.www.mospi.nic.in
• REDUCING MATERNAL MORTALITY:Strengthening the
World Bank Response .June, 2009
• Maternal & Child Mortality and Total Fertility Rates,
Sample Registration System (SRS),Office of Registrar
General, India.7th July 2011
• Trends in maternal mortality: 1990 to 2010. WHO,
UNICEF, UNFPA and The World Bank estimates
• How to reduce maternal deaths: rights and
responsibilities,department of international