Banjot Kaur 
New Delhi: India has made significant progress in reducing its maternal mortality ratio (MMR) but is still the fourth biggest contributor to the global rate of maternal mortality, according to an assessment released by the World Health Organisation (WHO) today on the occasion of World Health Day.
The WHO defines maternal death as thus: the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from incidental causes like accident.
This death may occur due to obstetric complications like postpartum haemorrhage – excessive bleeding post-delivery – or eclampsia – seizures in pregnant women. It may also occur due to medical complications arising due to any disease in the period encompassing a woman’s pregnancy.
The report said that India registered 19,000 maternal deaths in 2023 – contributing almost 7.2% to global mortality.
The biggest contributor was Nigeria (28.7%), followed by India, the Democratic Republic of Congo (7.2%) and Pakistan (4.1%).
Nigeria, the DRC and Pakistan registered 75,000, 19,000 and 11,000 maternal deaths, respectively, in 2023. Together, these four countries accounted for almost half (47%) of all maternal deaths globally in 2023.
India recorded 80 MMR deaths per 1,00,000 births. The WHO has divided countries into four categories according to their respective MMRs. Fourteen countries had a ‘high’ MMR (between 300 and 499), 43 countries had a ‘moderate’ MMR (between 100 and 299), 129 countries had a ‘low’ MMR (below 100) and 74 had a ‘very low’ MMR (below 20).
Thus, India falls in the bracket of ‘low’ MMR countries.
Most of the countries that had a ‘very low’ MMR were in Europe. The United States also has a ‘very low’ MMR. Besides India, countries in South America and a few in South-East Asia fall under the category of ‘low MMR’ countries.
A few countries in the African continent registered ‘moderate’ MMR and ‘high’ MMR. Some countries in Africa had an MMR between 500-999, and did not figure in any of the four categories due to their exceptionally high rates.
Global MMR. Photo: WHO.
The Indian scenario
India registered an MMR of 80 in 2023. This is the first time that India recorded MMR below 100 and has thus come in the category of ‘low MMR’ countries.
India’s MMR was 362 in 2000, 277 in 2005, 188 in 2010, 129 in 2015, 101 in 2020 and 80 in 2023. It is important to note here it was due to a continuous and consistent decline starting this century that India could reduce its MMR below 100 in 2023.
The annual reduction rate (AAR) in MMR is an important indicator to understand the progress made in lowering the MMR over the years.
From 2000-2015 the AAR for India was 7%. In other words, the annual decline in MMR on a year-on-year basis during these years was 7%. However, in the next six years – between 2016 and 2023 – the AAR declined by a single percentage point and dropped to 6%. In other words, the decline in MMR on a year-on-year basis in the last six years dropped marginally – by one percentage point – as compared to the first 15 years of this century.
One reason for this decline in the AAR could be the three years of the COVID-19 pandemic between 2020 and 2022. During this period, many routine healthcare services suffered as all efforts were diverted to contain the disease and its management. The WHO report has not quantified this effect for India.
The Union government has launched quite a few schemes to reduce MMR in collaboration with state governments in the last few years. However, the drop of 1% point in AAR in the last six years indicates that efforts to minimise the MMR or to sustain the reduction rates might require tweaks in policies or slightly better implementation on the ground.
“[The] coverage of life-saving health interventions and practices remains low due to gaps in knowledge, policies and availability of resources,” says UNICEF in an independent assessment about India.
“In a few areas there is a gap between the rich and the poor and an urban and rural divide. Access to health services is often dependent on a families’ or mother’s economic status and where they reside,” it says.
While the MMR seems to be reducing in India almost consistently, a bigger concern is inter-state divide. A few studies have also documented this trend and the available data also reflects it.
The states like Kerala, Maharashtra, Telangana, Andhra Pradesh, Tamil Nadu, Jharkhand, Gujarat, and Karnataka MMR has reduced to two digits but Bihar, Assam, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, Odisha, Rajasthan, Haryana, Punjab, West Bengal and Uttarakhand have exceptionally high MMRs. This divide is also reflected in the replies given in parliament by the government, one being in 2023.
One of the key reasons behind this gap is the supply side problem. “The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors,” says a paper published in 2021 and authored by M. Bhatia of the London School of Economics and Political Science and his colleagues.
EAG (Empowered Action Group) states are those which lag behind other states in terms of various indicators of human development. These states are: Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar Pradesh.
A glance at Rural Health Statistics 2021-22 released by the government of India also gives an indication about the huge gap in requirement and actual number of health personnel working in the EAG states, and the better ones which have reduced the MMR to two digits. For instance, the gap between the number of obstetricians/gynaecologists required and the number actually ‘in position’ is to the tune of 163% in Haryana. On the other hand, this difference in Karnataka is only 35%.
The authors of the paper have also stressed about addressing demand-side factors.
“Our findings suggest that demand side financing strategies including conditional cash transfers and pro-poor policies designed to address the scourge of maternal mortality in the poorer sections of the society in rural India have an important role to play by reducing the financial barriers in accessing maternal health services,” the authors say.
Preventable causes
Most of the causes of maternal deaths in India, and across the globe are preventable.
“Severe bleeding, high blood pressure, pregnancy-related infections, complications from unsafe abortion, and underlying conditions that can be aggravated by pregnancy (such as HIV/AIDS and malaria) are the leading causes of maternal deaths. These are all largely preventable and treatable with access to high-quality and respectful healthcare,” the WHO report says.
It recommends that by addressing inequities in access to and quality of sexual, reproductive, maternal and newborn health care, ensuring universal health coverage, addressing all causes of maternal mortality and morbidity and strengthening health systems to respond to the needs of just not women but also girls, the MMR could be substantially brought down across the world.
What is a matter of concern though is the global MMR stood at 197 in 2023. Thus, the number of maternal deaths registered per 1,00,000 births was 197.
The WHO estimates if the current global trajectory and its annual rate of reduction – which is currently 1.6% – continues, the world would fail to achieve the sustainable goal target (SDG) related to maternal deaths, by 2020.
The goal is to reduce maternal deaths to 177 per 1,00,000 births by 2030. This would require an annual reduction rate of 14.1% (year-on-year basis) over the next seven years, which appears as of now to be a difficult task.