Maternal Deaths in India: A Review of Trends and Programmes

High-quality services during childbirth in a health care facility reduce maternal morbidity and mortality. High maternal mortality in India is a critical concern. In an attempt to decrease the maternal mortality rate (MMR), the Government of India has launched many programmes. This article discusses the trends in maternal mortality in India with the inter-state disparities. As per Sample Registration System (SRS), MMR in India was estimated to be 556 in 1990, but globally it was only 385 at that time. India has achieved about a 77% reduction in maternal mortality compared to the global average of 43% between 2005 and 2017, but a huge inter-state disparity in maternal death still exists. Approximately 65%-75% of the estimated maternal deaths in India occur in a few states, including the eight Empowered Action Group (EAG) states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, and Uttarakhand), and Assam. For instance, the MMR reported for Assam (state which has the highest MMR) was 215 in 2017-18 which is five times higher than that of Kerala (43), which has the least MMR of all states. Most of the maternal deaths are due to direct causes and are largely preventable and treatable. There was a consistent reduction in MMR as a result of a number of interventions and programmes including Janani Suraksha Yojana (JSY) which helped in surging institutional deliveries.

Childhood undernutrition inequalities in empowered action group states of India: evidence from NFHS, 2006-2016

Background: Child undernutrition is a major public health problem in many low and middle income countries and malnutrition alone accounted for 45% (3 million deaths annually) deaths among under-five children. Malnutrition is the concealed cause of one out of every two such deaths. A study was undertaken to examine the trends, determinants and socioeconomic-related inequalities in childhood undernutrition in empowered action group (EAG) states, India. The secondary data of the two rounds of National Family Health Survey, NFHS-3 (2005-06) and NFHS-4 (2015-16) comprising of 16,802 and 128,400 children aged 0-59 months respectively was analysed.Methods: Non-linear Fairlie decomposition was used to identify and quantify the separate contribution of different socioeconomic characteristics in gap of childhood malnutrion between 2006 and 2016.Results: Results show that the prevalence of undernutrition has decreased in EAG states during the last one decade, but the prevalence of wasting is remained almost same as 10 years back. The decomposition analysis shows that maternal education, household wealth and place of residence were contributing to socioeconomic inequality in childhood undernutrition from 2006 to 2016.Conclusions: There is a need to adopt different strategies of health policy intervention. It is important to have policies towards improving female literacy in the EAG states because maternal education plays a vital role in child health and literacy rate is very low among women in EAG states. The existence of a functional health insurance system and increasing universal coverage are recommended to mitigate child undernutrition, so that the vulnerable and deprived populations who are not able to access health care facilities, can easily access health care services for early detection and treatment of undernutrition without any financial constraint.

Maternal health situation in the empowered action group states: how far we reached: a comparative analysis of national family health survey-3 and 4

Background: Maternal health constitutes the health of women during pregnancy, childbirth, and the post-partum period. India is one the biggest contributor to maternal mortality, among all the states of India, the Empowered Action Group (EAG) states contributes 61.5% of total mortality, keeping in this view the study compared the NFHS-3 and NFHS-4 survey of the maternal health condition of EAG states of India and evaluated the relationship between maternal health status and predictors of EAG states of India in NFHS-3 and NFHS-4.Methods: This cross-sectional study adopted descriptive secondary data analyses of two rounds of nationally representative sample surveys NFHS-3 and NFHS-4. The data were obtained by the demographic and health survey website after proper procedures and compared for various maternal health indicators of EAG states.Results: In this investigation, progress has been observed from NFHS-3 to NFHS-4 however, the progress is very positive promising to growth. Where their full (antenatal care) ANC indicator growth is very steady. Education and domestic violence are still hampering the growth of full maternal health wellbeing.Conclusions: Given the status of maternal health in India and more especially in EAG states, more improvement in the performance of maternal health-related activities is highly necessary for which health system strengthening coupled with strong political will and community mobilization are some of the urgent strategies required in the EAG states. Above all community, awareness has a greater role in improving the health status in these.

Pro-poor policies and improvements in maternal health outcomes in India

Background Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997–2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India. Methods This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015–16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India. Results On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors. Conclusions The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India’s impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

Maternal health care service utilization among young married women in India, 1992–2016: trends and determinants

Background Maternal deaths among young women (15–24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India. Methods The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992–93, 1998–99, 2005–06 and 2015–16. Young married women aged 15–24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05. Results The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992–2016. SBA utilization was 88 and 83% during 2015–16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time. Conclusions In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states.

Changes in socio-economic inequality in nutritional status among children in EAG states, India

Objective The primary purpose of this study is to examine changes in socioeconomic inequality in nutritional status (stunting and underweight) among children in Empowered Action Group (EAG) states. Design The study is based on the most recent two wave’s cross-sectional data from the National Family Health Survey (NFHS) conducted in 2005-06 (NFHS-3) and 2015-16 (NFHS-4). The study used height-for-age (stunting) and weight-for-age (underweight) of children as anthropometric indicators. Setting EAG states including Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar Pradesh in India Participants The study includes a total of 11858 (NFHS-3) and 92630 (NFHS-4) children under five years Result The socioeconomic inequality in stunting remained unchanged in all EAG states. At the same time, the inequality in underweight decreased during 2005-2016. On decomposing, the factors contributing to socioeconomic inequality revealed that household wealth index, mother’s education, and mother’s nutritional status were the largest contributors to stunting (47%, 24%, and 8%) and underweight (51%, 21%, and 16%) respectively in 2015-16. Conclusion The study concluded the socioeconomic inequality in underweight among children under five years increased over the years in EAG states in India. Altogether, household wealth index, mother’s education, and mother’s nutritional status contributed to nearly 80% to inequality in stunting and 90% to inequality in underweight in 2015-16. Hence, efforts should be made to minimize the socioeconomic inequality in the nutritional status of children, particularly in EAG states in India.

Prevalence and risk factors of anaemia among men: A study based on Empowered Action Group states, India

Background: Despite various programmes initiated by the Government of India, the nutritional indicators are not encouraging, as several problems like undernutrition, malnutrition and anaemia – still persist in the country, especially in the Empowered Action Group (EAG) states. Aim: Because of the dearth of studies regarding anaemia among men in India, the present study aimed to determine its prevalence in this population in the EAG states and to analyse its geographical and socio-demographic determinants. Methods: The study utilized nationally representative, cross-sectional survey data from round 4 of the National Family Health Survey conducted in 2015–16. Bivariate analysis along with binary logistic regression were performed to assess the predictors of anaemia among men in the EAG states. Results: Around a quarter of the men in the EAG states suffered from anaemia. A similar high-prevalence pattern was observed across the EAG states. Wherein, Bihar and Jharkhand had the highest prevalence of anaemia while Uttarakhand showed the lowest. Age, place of residence, marital status and caste were positively associated with the likelihood of anaemia among men in the EAG states. Conclusions: Focusing on the EAG states, this study considered the severity of anaemia as a public health problem among men. Strategies to reduce the burden of anaemia among this population are needed. The government should formulate programmes targeting anaemia specifically, and improving the nutritional status among men in general in the EAG states.

Inequalities and policy gaps in maternal health among Empowered Action Group (EAG) States in India: Evidence from Demographic Health Survey

Health inequality in maternal health is one of the serious challenges currently faced by public health experts. Maternal mortality in Empowered Action Group (EAG) states is highest and so are the health inequalities prevalent. We have made a comprehensive attempt to understand maternal health inequality and the risk factors concerning the EAG states in India, using recent data of Demography Health Survey of India (2015-16). Bi-variate, multivariate logistic regression, and concentration indices were used. The study has measured the four outcome variables of maternal health namely antenatal care of at least 4 visits, institutional delivery, contraceptive use, and unmet need. The study revealed that better maternal health is heavily concentrated among the richer households, while the negative concentration index of unmet need clearly reflected the greater demand for higher unmet need among the poor households in the EAG states of India. Challenges of inequalities still persist at large in maternal health, but to achieve better health these inequalities must be reduced. Since inequality mainly affects the poor households due to a lower level of income. Therefore, specific measures must be taken from a demand-side perspective in order to enhance their income and reduce the disparities in the EAG states of India.