Maternal mortality in India is the maternal death of a woman in India during pregnancy or after pregnancy, including post-abortion or post-birth periods. [1] Different countries and cultures have different rates and causes for maternal death. [2] Within India, there is a marked variation in healthcare access between regions and in socioeconomic factors, accordingly, there is also variation in maternal deaths for various states, regions, and demographics of women. [3]
Pregnancy involves a vulnerability that put women at risk of dying, and India is one of many countries who record a high number of pregnancy-related deaths of women each year. [4]
Women die as a result of complications during and following pregnancy and childbirth or abortion. Most of these complications develop during pregnancy are easily preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of a woman’s care.
India contributes one-fifth of the global burden of absolute maternal deaths; however, it has experienced an estimated 4.7% annual decline in maternal mortality ratio (MMR), [5] [6] and 3.5% annual increase in skilled birth attendance since 1990. [5] [7]
Ninety-four percent (94%) of all maternal deaths occur in low and lower middle-income countries. [8] [9] In September 2000, the United Nations, faced with the enormous maternal death toll in India and other developing countries, pledged as its fifth Millennium Development Goal (MDG 5) that the global MMR would be reduced to a quarter of its 1990 level by 2015. India is a signatory to the Millennium Declaration adopted at the United Nations General Assembly in September 2000, and consistently reaffirmed its commitment towards the eight development goals. These MDG targets were in convergence with India’s own national development goals to reduce poverty and other areas of deprivation. [10] In 2018 the World Health Organization (WHO) congratulated India for great reduction in maternal mortality since 2005, [11] especially in recent years, reducing the maternal mortality ratio (MMR) by 77%, from 556 per 100 000 live births in 1990 to 130 per 100 000 live births in 2016, which was considered by WHO to be a remarkable feat in contrast with the global maternal mortality reported to have experienced a decline of 43%. Prior to that, various reports described high rates of maternal mortality in India, [12] [13] from which WHO and other international bodies concluded that India could not reach the Millennium Development Goals (MDG).
Maternal deaths being a rare event require a large sample size to provide robust estimates. In order to enhance the Sample Registration System (SRS) sample size, results were derived by following the practice of pooling three years' data to yield reliable estimates of maternal mortality. [14] The first report on maternal mortality in India (1997-2003), describing trends, causes and risk factors, was released in October 2006. [15]
In 2005, a woman's lifetime risk of maternal death in India was estimated to be 1 in 70. Similarly, the maternal mortality ratio (MMR; number of maternal deaths per 100,000 live births) in India was 450. [16]
In 2010, approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Statistics showed that up until 2010, more than half a million women—most of them living in developing countries—dies from pregnancy- or childbirth-related complications every year, and about a quarter of these “maternal” deaths occurred in India. [16]
India showed a steady decline in maternal mortality, from 254 in every 100 000 live births in 2004-06 to 178 in every 100 000 live births in 2010-12. [17]
As per Sample Registration System (SRS), 2011-13 reports published by Registrar General of India, Maternal Mortality Ratio (MMR) was 167 per 1,00,000 live births in the country. Under the Millennium Development Goal (MDG) 5, the target is to reduce Maternal Mortality Ratio (MMR) by three quarters between 1990 and 2015. This translates to reducing the MMR from 560 in 1990 to 140 in 2015. [18] [19]
In 2014, India was recognized to have contributed one-fifth of the global burden of absolute maternal deaths, while experiencing an estimated 4.7% decline in its Maternal Mortality Ratio which stood at 174 per 100,000 live births in India. [20]
According to the Office of the Registrar General, the ratio has declined from 130 in 2014-2016 to 122 in 2015-17, registering a 6.15 per cent reduction since the last survey figures of 2014-2016. India’s present MMR is below the Millennium Development Goal (MDG) target and puts the country on track to achieve the Sustainable Development Goal (SDG) target of an MMR below 70 by 2030. [21]
From 1980-2015 eclampsia is the cause of 1.5% of maternal deaths in India. [22] Over that time, the number of women who experience this disease has been the same, but also there has been a slight reduction in the number of maternal death from the condition. [22]
Approximately two-thirds of all maternal deaths are primarily caused by major complications, including severe bleeding (typically occurring after childbirth), infections (commonly arising after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), delivery-related complications, and unsafe abortions. [23] Between 50% and 98% of maternal deaths result from direct obstetric causes such as hemorrhage, infection, hypertensive disorders, ruptured uterus, hepatitis, and anemia. Additionally, around 50% of maternal deaths caused by sepsis are associated with illegal induced abortions. [24]
According to the Sample Registration System Bulletin-2016, India has registered a 26.9 per cent reduction in maternal mortality ratio (MMR) since 2013. The MMR has declined from 167 in 2011-2013 to 130 in 2014-2016, to 122 in 2015-17, to 113 in 2016-2018. According to the National Health Policy (NHP) 2017, India set a goal to reduce its Maternal Mortality Rate (MMR) to below 100 per lakh live births by the year 2020. The SRS estimates that India had an MMR of 97 per lakh live births during the period of 2018-2020, accomplishing this target within the specified timeframe. [25]
MMR (per 100,000 live births) | 2004-06 [26] | 2007-09 [27] | 2010-12 [28] | 2011-13 [29] | 2014-16 [30] | 2015-17 [31] | 2016-18 [32] | 2018-20 [33] |
---|---|---|---|---|---|---|---|---|
India Total | 254 | 212 | 178 | 167 | 130 | 122 | 113 | 97 |
Assam | 480 | 390 | 328 | 300 | 237 | 229 | 215 | 195 |
Bihar | 312 | 261 | 219 | 208 | 165 | 165 | 149 | 118 |
Jharkhand | 76 | 71 | 56 | |||||
Madhya Pradesh | 335 | 269 | 230 | 221 | 173 | 188 | 173 | 173 |
Chhattisgarh | 141 | 159 | 137 | |||||
Odisha | 303 | 258 | 235 | 222 | 180 | 168 | 150 | 119 |
Rajasthan | 388 | 318 | 255 | 244 | 199 | 186 | 164 | 113 |
Uttar Pradesh | 440 | 359 | 292 | 285 | 201 | 216 | 197 | 167 |
Uttarakhand | 89 | 99 | 103 | |||||
EAG & Assam Subtotal | 375 | 308 | 257 | 246 | 188 | 175 | 161 | 137 |
Andhra Pradesh | 154 | 134 | 110 | 92 | 74 | 74 | 65 | 45 |
Telangana | 81 | 76 | 63 | 43 | ||||
Karnataka | 213 | 178 | 144 | 133 | 108 | 97 | 92 | 69 |
Kerala | 95 | 81 | 66 | 61 | 46 | 42 | 43 | 19 |
Tamil Nadu | 111 | 97 | 90 | 79 | 66 | 63 | 60 | 54 |
South Subtotal | 149 | 127 | 105 | 93 | 77 | 72 | 67 | 49 |
Gujarat | 160 | 148 | 122 | 112 | 91 | 87 | 75 | 57 |
Haryana | 186 | 153 | 146 | 127 | 101 | 98 | 91 | 110 |
Maharashtra | 130 | 104 | 87 | 68 | 61 | 55 | 46 | 33 |
Punjab | 192 | 172 | 155 | 141 | 122 | 122 | 129 | 105 |
West Bengal | 141 | 145 | 117 | 113 | 101 | 94 | 98 | 103 |
Other States | 206 | 160 | 136 | 126 | 97 | 96 | 85 | 77 |
Other Subtotal | 174 | 149 | 127 | 115 | 93 | 90 | 83 | 76 |
RBI categorization of states are usually organized into three groups, especially at the regional level, to understand the maternal mortality situation in the country better and to map the changes that have taken place: EAG, southern states and "other" states.[ citation needed ]
EAG states comprise Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand, and Assam. The southern states are Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu and the "other" states categories cover the remaining states and Union territories.
Kerala, Maharashtra and Tamil Nadu have already met the sustainable development goals target of 70 per 100,000 MMR, while Andhra Pradesh and Telangana are within range.
Among southern states, the decline in MMR has been from 77 to 72 per 100,000 live births, from 93 to 90 in the other states. The decline has been most significant in empowered action group (EAG) states and Assam from 188 to 175. [34]
In the recently released report on maternal mortality ratio (MMR) prepared by the union government, Uttarakhand has fared significantly well recording 89 deaths per lakh deliveries between 2015 and 2017 as against the national average of 122. [35]
According to officials of National Health Mission (NHM) in Uttarakhand, the state stood at 8th spot among the 19 top states in the country. Notably the last survey, which clubbed Uttarakhand and the neighboring Uttar Pradesh as one, ranked the two states at the 15th spot. It stated that the MMR in the two states (combined) between 2014 and 2016 stood at 201 maternal deaths per lakh births. [35]
The rates for using maternal healthcare is the same for rural and urban women in wealthier Indian states. [36] In poorer states, urban women access healthcare much more often than rural women. [36]
In November 2016, the government launched the Pradhan Mantri Surakshit Matritva Abhiyan, or the Prime Minister Safe Pregnancy Scheme, which aims to provide free and comprehensive care on the ninth day of every month during pregnancy. Pregnant women are provided special, free ante-natal checks in their second or third trimester at government health care facilities, including ultrasounds, blood and urine tests. [37]
Full ANC refers to at least four antenatal visits, one tetanus toxoid (TT) injection and iron folic acid tablets or syrup taken for 100 or more days. Yet, getting these facilities to women is a challenge, especially in poorer states. No more than 3.3 per cent of pregnant women in Bihar reported receiving full antenatal care, lowest among states. [37]
The rates for using maternal healthcare is the same for rural and urban women in wealthier Indian states. In poorer states, urban women access healthcare much more often than rural women. [38]
The BIMARU states experience a range of problems including maternal mortality. [39]
Assam has the highest rate of maternal mortality in India. [40] Within Assam, some of the highest rates of maternal mortality are among tea plantation workers. [40]
A regional program in Andhra Pradesh seeks to ask doctors and nurses about the causes of maternal mortality in local communities. [41] The general circumstance is that maternal mortality has different causes in different places, but if clinics knew the common causes for that area, then they would be better prepared to prevent future deaths. [41]
As compared to other states, Bihar has relatively low rates for use of medical care services. [42]
A 2019 survey in rural West Bengal reported that the "three delays" caused maternal death. [43] Those are delay in deciding to go to the clinic, delay in actually arriving at the clinic, and delay in getting care at the clinic. [43]
Karnataka has the highest rate of maternal mortality in South India. [44] In interviews, mothers reported that when they did not use healthcare services, their reasons included lack of access to transport to the clinic, the cost of care, and low value in a clinic visit. [44] When a mother dies in this region it is often in the postpartum period. [44]
Surveys have found that women in UP who are more educated and have more money tend to use more maternal health services. [45]
In India, among other factors, coordination between levels in the delivery system and fragmentation of care account for the poor quality of maternal health care, which is worsened by mass illiteracy. [12] Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to high quality care in pregnancy, and during and after childbirth. [46]
Various civil organizations have suggested effective strategies for reducing MMR in India:
In 2018 the World Health Organization noted four recent changes in India which had lowered maternal mortality: [47]
Before 2017 the government focus on maternal mortality was learning about the causes of death to develop a plan for prevention. [48] In 2017 the Indian government shifted focus in its programs to instead detect risks then offer healthcare to prevent the death. [48]
A 2016 national survey expected to find that if a household loses a woman to maternal death, then other women in the household will seek more clinic services during pregnancy and after childbirth. [49] Contrary to expectation, the study instead found that after a maternal death, women instead avoid hospitals and instead seek support from a traditional birth attendant. [49] Reasons for this vary, but part of the explanation is that many of these women could go to the hospital for care but choose to avoid doing so. [49]
Social factors which influence maternal mortality in India are income inequality in India; level of access to Prenatal care and care in the postpartum period; level of woman's education; the position of the mother's community in the regional rural-urban divide; the mother's access to nutrition during pregnancy; the degree of local sanitation; and the caste position of the mother.[ citation needed ]
The same health monitoring systems which track maternal mortality could also ask women to report other problems, such as lack of good treatment from hospital staff. Healthcare in India measures and reports maternal mortality. [50] Offering general support services to women could improve many aspects of health care. [50]
From 2000-2015 India participated in the Millennium Development Goal to improve maternal health.[ citation needed ]
The Government of India has started various public health initiatives to provide a safe and secure environment. Some of these initiatives are -
Government have also taken initiatives on improving the infrastructure of the country by improving roads and providing free ambulance services at PHC. [55]
In 2018 the World Health Organization congratulated India for great reduction in maternal mortality since 2005. [47]
Previous to that, various reports described high rates of maternal mortality in India. [56] [57]
Maternal mortality is challenging to study because it is fairly uncommon, it can happen for various reasons, and it is challenging to report. [36] The first nationally representative study of maternal mortality in all of India was in 2014. [36]
Two major global studies in 2015 report maternal mortality in India and contribute to national planning. One study is the Global Burden of Disease Study, which in 2015 for the first time published a national report about India. [58] [59] The other is the 2015 report of the United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG). [60] For the earlier 2013 versions of these two studies, researchers noted that they used different data and analysis to come to different conclusions about changes over time of maternal mortality in India. [61]
In 2017 a report found no significant impact following a large study of 160,000 pregnant women who participated in a one-week educational program to improve maternal health and childbirth outcomes. [62]
Infant mortality is the death of an infant before the infant's first birthday. The occurrence of infant mortality in a population can be described by the infant mortality rate (IMR), which is the number of deaths of infants under one year of age per 1,000 live births. Similarly, the child mortality rate, also known as the under-five mortality rate, compares the death rate of children up to the age of five.
Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.
The maternal mortality ratio is a key performance indicator (KPI) for efforts to improve the health and safety of mothers before, during, and after childbirth per country worldwide. Often referred to as MMR, it is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management. It is not to be confused with the maternal mortality rate, which is the number of maternal deaths in a given period per 100,000 women of reproductive age during the same time period. The statistics are gathered by WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. The yearly report started in 1990 and is called Trends in Maternal Mortality. As of the 2015 data published in 2016, the countries that have seen an increase in the maternal mortality ratio since 1990 are the Bahamas, Georgia, Guyana, Jamaica, Dem. People’s Rep. Korea, Serbia, South Africa, St. Lucia, Suriname, Tonga, United States, Venezuela, RB Zimbabwe. But according to Sustainable Development Goals report 2018, the overall maternal mortality ratio has declined by 37 percent since 2002. Nearly 303,000 women died due to complications during pregnancy.
Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.
Women's health differs from that of men's health in many unique ways. Women's health is an example of population health, where health is defined by the World Health Organization (WHO) as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". Often treated as simply women's reproductive health, many groups argue for a broader definition pertaining to the overall health of women, better expressed as "The health of women". These differences are further exacerbated in developing countries where women, whose health includes both their risks and experiences, are further disadvantaged.
Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.
Tropical diseases, especially malaria and tuberculosis, have long been a public health problem in Kenya. In recent years, infection with the human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS), also has become a severe problem. Estimates of the incidence of infection differ widely.
A maternal near miss (MNM) is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criterion of choice for evaluating women's health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.
Unintended pregnancies are pregnancies that are mistimed or unwanted at the time of conception, also known as unplanned pregnancies.
Family planning in India is based on efforts largely sponsored by the Indian government. From 1965 to 2009, contraceptive usage has more than tripled and the fertility rate has more than halved, but the national fertility rate in absolute numbers remains high, causing concern for long-term population growth. India adds up to 1,000,000 people to its population every 20 days. Extensive family planning has become a priority in an effort to curb the projected population of two billion by the end of the twenty-first century.
Uganda, like many developing countries, has high maternal mortality ratio at 153 per 100,000 live births. According to the World Health Organization (WHO), a maternal death is 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. In situations where attribution of the cause of death is inadequate, another definition, pregnancy-related death was coined by the US Centers for Disease Control (CDC), defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
Maternal health in Angola is a very complicated issue. In the Sub-Saharan region of Africa where Angola is located, poor maternal health has been an ongoing problem contributing to the decreased level of health in the population in the early 21st century.
In reproductive health, obstetric transition is a concept around the secular trend of countries gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization. This concept was originally proposed in the Latin American Association of Reproductive Health Researchers in analogy of the epidemiological, demographic and nutritional transitions.
Both maternal and child health are interdependent and substantially contributing to high burden of mortality worldwide. Every year, 289 000 women die due to complications in pregnancy and childbirth, and 6.6 million children below 5 years of age die of complications in the newborn period and of common childhood diseases. Sub-Saharan Africa (SSA), which includes Tanzania, contribute higher proportion of maternal and child mortality. Due to considerable proportion of mortality being attributed by maternal and child health, the United Nations together with other international agencies incorporated the two into Millennium Development Goals (MDGs) 4 and 5. In this regard, Tanzania through the Ministry of Health and Social Welfare (MoHSW) adopted different strategies and efforts to promote safe motherhood and improve child survival. Similarly, in an effort to improve maternal and child health, Tanzania's government has declared maternal and child health services to be exempt from user fees in government facilities.
Maternal healthcare in Texas refers to the provision of family planning services, abortion options, pregnancy-related services, and physical and mental well-being care for women during the prenatal and postpartum periods. The provision of maternal health services in each state can prevent and reduce the incidence of maternal morbidity and mortality and fetal death.
The Maternal Mortality and Morbidity Task Force was started by the Department of State in 2013 to help reduce maternal death in Texas. The task force and DSHS must submit a joint report on the findings of the task force and recommendations to the governor, lieutenant governor, speaker of the House of Representatives, and appropriate committees of the Texas Legislature by September 1 of each even-numbered year, beginning September 1, 2016. The maternal mortality ratio (MMR) for the state of Texas was concluded to be the highest in the developed world in 2016, with the maternal mortality rate (MMRate) of the state surging beyond the poor MMRate of 48 states of the US at 23.8% to a remarkably high 35.8%.
Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. According to a 2010-2011 report although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.
Abuse during childbirth is generally defined as interactions or conditions deemed humiliating or undignified by local consensus and interactions or conditions experienced as or intended to be humiliating or undignifying. Bowser and Hill's 2010 landscape analysis defined seven categories of abusive or disrespectful care, including physical abuse, non-consented clinical care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in health facilities.
Black maternal mortality in the United States refers to the death of women, specifically those who identify as Black or African American, during or after child delivery. In general, maternal death can be due to a myriad of factors, such as the nature of the pregnancy or the delivery itself, but is not associated with unintentional or secondary causes. In the United States, around 700 women die from pregnancy-related illnesses or complications per year. This number does not include the approximately 50,000 women who experience life-threatening complications during childbirth, resulting in lifelong disabilities and complications. However, there are stark differences in maternal mortality rates for Black American women versus Indigenous American, Alaska Native, and White American women.
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