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Source: The Hindu

Context

The Maternal Mortality Ratio (MMR) in India is declining; however, certain states need to address basic and systemic issues.

What do MMR trends indicate about regional inequities in India?

• Declining National MMR: India's MMR fell from 103 (2017-19) to 93 (2019-21), indicating a moderate but steady improvement.
• Kerala ranks first with an MMR of 20, suggesting strong institutional care and maternal health knowledge.
• Southern states (such as Tamil Nadu and Andhra Pradesh) do better (MMR < 50–60), whereas EAG states like Madhya Pradesh (175) and Assam (167) remain critical zones.
• "Other" States: Maharashtra (38) and Gujarat (53) have made significant improvements, but Punjab (98) and Haryana (106) are still struggling.

Understanding Maternal Death

• Maternal Death refers to the death of a woman during pregnancy or within 42 days of pregnancy termination, from causes related to pregnancy or its management, excluding accidental/incidental causes.
  
  
• It is quantified as the Maternal Mortality Ratio (MMR), i.e., number of maternal deaths per 100,000 live births during a specific time period.

India’s National MMR Status

• As per the Sample Registration System (SRS) 2019–21, India’s MMR stands at 93.
  
  
• India has shown consistent progress in reducing maternal mortality:
  
  
• 103 (2017–19)
  
  
• 97 (2018–20)
  
  
• 93 (2019–21)

State-wise Classification of MMR

1. Empowered Action Group (EAG) States & Assam

• Includes: Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand, and Assam
  
  
• Assam has the highest MMR at 167.
  
  
• Jharkhand performs best within this group with MMR of 51.
  
  
• Bihar, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand have MMRs between 100–151.
  
  

2. Southern States

• Includes: Andhra Pradesh, Telangana, Karnataka, Kerala, Tamil Nadu
  
  
• Kerala has the lowest MMR in India at 20.
  
  
• Karnataka has the highest in this group at 63.
  
  

3. Other States and Union Territories

• Covers all other regions not in the above groups.
  
  
• Maharashtra: MMR of 38
  
  
• Gujarat: MMR of 53

How are the three key delays contributing to maternal deaths?

• Postpone in Decision-Making at Home: Families frequently fail to recognize warning signs during pregnancy or childbirth and postpone seeking medical attention. For example, a pregnant lady who is bleeding excessively may not be sent to the hospital right once due to familial neglect, financial restraints, or the notion that delivery is natural.
• Delay in Accessing a Healthcare Facility: A lack of timely transportation from remote or rural places impedes access to trained birth attendants or emergency care. For example, a woman in a tribal area may spend hours traveling to a hospital due to poor roads or a shortage of ambulances, culminating in birth en route.
• Delay in Receiving Adequate Service at the Facility: Even after arriving at the hospital, service may be delayed owing to a lack of doctors, operating rooms, or blood supplies. For example, a lady having uterine rupture may not be able to have emergency surgery because the anaesthetist is unavailable or the occupational therapist is not prepared.

Maternal Deaths: The Three Delays Model

Delay in Decision-Making to Seek Care

• Rooted in poor health literacy, financial insecurity, and gendered social norms.
  
  
• Families often underestimate pregnancy complications, considering childbirth routine.
  
  
• This delay can be fatal if early warning signs are ignored.
  
  
• Community engagement has helped reduce this delay:
  
  
• ASHA workers, self-help groups, and financial incentives under the National Rural Health Mission (NRHM) have promoted institutional deliveries.
  
  

Delay in Reaching Healthcare Facilities

• Caused by geographic isolation, inadequate transportation, and poor road connectivity, particularly in rural and tribal areas.
  
  
• The 108-ambulance service and emergency transport under the National Health Mission (NHM) have provided relief.
  
  
• However, these measures have only partially addressed the challenge.
  
  

Delay in Receiving Adequate Care at the Facility

• Considered the most inexcusable delay.
  
  
• Results from systemic issues such as:
  
  
• Understaffed hospitals
  
  
• Non-functional operation theatres
  
  
• Lack of blood banks
  
  
• Shortage of skilled obstetricians and anaesthetists
  
  
• Delayed emergency response and lab results
  
  
• Such issues often lead to avoidable maternal deaths.

Model of Success: Kerala’s Proactive Approach

Learning from Kerala:

• Kerala’s maternal healthcare is a national and global benchmark.
  
  
• Introduction of Confidential Review of Maternal Deaths led by Dr. V.P. Paily has helped identify and rectify systemic failures.
  
  
• Notable clinical strategies:
  
  
• Uterine artery clamps
  
  
• Management of amniotic fluid embolism
  
  
• Treatment of antenatal depression
  
  
• Kerala’s model addresses both physical and psychological health.
  
  
• Backed by:
  
  
• Routine audits
  
  
• Robust training programs
  
  
• Active community involvement

Recommendations and Way Forward

• Enhance Antenatal Care:
  
  
• Promote early registration, regular check-ups, and management of pre-existing conditions.
  
  
• Strengthen Institutional Deliveries:
  
  
• Continue awareness campaigns and incentive schemes, especially in high-risk zones.
  
  
• Upgrade First Referral Units (FRUs):
  
  
• Every district should have fully functional FRUs with 24×7 blood banks and emergency obstetric services.
  
  
• Expand Human Resources:
  
  
• Train and deploy more obstetricians, anaesthetists, and nurses in underserved areas.
  
  
• Implement task-sharing models and telemedicine to bridge workforce gaps.
  
  
• Improve Transport Mechanisms:
  
  
• Expand ambulance networks and integrate them with community health infrastructure.

Practice Question Q. What are the key medical and socio-economic factors that endanger the lives of pregnant women in India?