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EDITORIAL
Year : 2017  |  Volume : 61  |  Issue : 4  |  Page : 231-232  

Maternal mortality: An equity issue


1 Former Director of Medical Education, Assam and Former Professor and Head of Department of Community Medicine, Gauhati Medical College, Presently Vice Chancellor, Srimanta Sankaradeva University of Health Sciences, Assam, Member, Advisory Board, IJPH, India
2 Associate Professor, Department of Community Medicine, Fakhruddin Ali Ahmed Medical College, Barpeta, Assam, India

Date of Web Publication6-Dec-2017

Correspondence Address:
Umesh Chandra Sarma
Former Director of Medical Education, Assam and Former Professor and Head of Department of Community Medicine, Gauhati Medical College, Presently Vice Chancellor, Srimanta Sankaradeva University of Health Sciences, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_323_17

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How to cite this article:
Sarma UC, Kakoty SD. Maternal mortality: An equity issue. Indian J Public Health 2017;61:231-2

How to cite this URL:
Sarma UC, Kakoty SD. Maternal mortality: An equity issue. Indian J Public Health [serial online] 2017 [cited 2017 Dec 11];61:231-2. Available from: http://www.ijph.in/text.asp?2017/61/4/231/220063



“Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”

- Mamoud Fathalla, President (International Federation of Gynecology and Obstetrics), World Congress, Copenhagen, 1997

India has missed the Millennium Development Goal (MDG) target of 108 maternal mortality ratio (MMR) by 2015 and is committed to lower it to 100 by 2020.[1] Currently, our country accounts for 15% of maternal deaths in the world, and hence, faster reduction of MMR is of national as well as international concern. Maternal mortality is an avoidable tragedy.

There is an appreciable decline in MMR from 254 (2004–2006), 212 (2007–2009), 178 (2010–2012), to 167 (2011–2013).[2] The immediate cause of death is a biomedical event, but the contributory causes are diverse. Health system and social and developmental factors immensely contribute to it. It is an outcome of inequity – both in health and social sectors. Levels of per-capita income, social factors, and MMR are positively related.[3] Inequality in health as an outcome of social and economic inequality has been emphasized for long.[4] Although there is a decline in maternal mortality, there is considerable interstate and intrastate variation, ranging from 300 in Assam to 61 in Kerala. An empowered action group of states of the National Health Mission contributes to the maximum maternal deaths. Reduction in MMR over three periods 2001–2006, 2004–2009, and 2007–2012 was 47, 42, and 37 points, respectively.[3] Poor-performing states had rapid decline and better-performing states had relatively less decline. This rapid decline in a relatively short time is expected and is due to scaling up of health services and reforms within the health system through Reproductive and Child Health Programme and National Rural Health Mission. This difficult now as most maternal deaths in India are associated with social determinants such as poverty, poor education, low socioeconomic condition, and marginalized population. In India, many researchers have demonstrated the link between maternal death and social inequity.[5],[6],[7],[8],[9],[10] Even within better performing states like Kerala, there is inter-district variation because of social constructs.[11] Maternal and Perinatal Death Review has yielded many insights into nonmedical determinants of maternal deaths.[12] Thus, vulnerable and disadvantaged groups must be identified for priority interventions to bring down maternal mortality.

Maternal death review (MDR) system has been initiated in India in 2010. With wider involvement and incentives to accredited social health activist for reporting maternal deaths, we believe that not all but most maternal deaths are now being at least reported. Although each maternal death should be dissected for reasons of death in MDR, this system is not functioning as expected. Only about two-third deaths are reviewed by the district committee and most analysis is yet confined to biomedical causes of death rather than finding gaps in health system and instituting corrective measures.[13] Our experience in a district of Assam in 2015–2016 is that MDR system identified 95% maternal deaths, but community-based verbal autopsy was carried out only in 20% of maternal deaths.[14] The National Health Policy 2017 strongly recommends strengthening of general health system to prevent and manage maternal complications to ensure continuity of care and emergency service for maternal health.[1]

Maternal mortality can be due to direct and indirect obstetric causes. Among the direct and indirect causes, postpartum hemorrhage, pregnancy-induced hypertension, and anemia are still major causes of maternal death in India. At present, antenatal coverage is near-universal or will be universal implying the accessibility to health system. The challenge now will be to provide quality antenatal care. Quality antenatal care can directly address two major causes of maternal mortality, namely, anemia and preeclampsia. While conducting verbal autopsy, we identified risk factors during pregnancy in 50% maternal death.[14] Thus, the concept of maternal care now has to expand from “birth preparedness” to “complication preparedness” for the peripheral level health workers.

Besides district-level review as recommended in the guideline, MDR on a case-to-case basis at the block level jointly by the Medical Officer of PHC and Block Development Officer will highlight the reach of health and social sector programs and areas for action in both sectors. Such an exercise can also provide information about workable areas of primary and secondary delay in maternal deaths. Purposeful MDR can help in reduction of maternal death and Tamil Nadu has demonstrated it.[15] A maternal death audit and near-miss death audit in all tertiary hospitals will address the issue of tertiary delay in maternal death. Initiating surveillance of maternal death at a district level and conducting confidential enquiry into maternal death will also provide further information. Hopefully, all these options have already been recommended in the revised guidelines for maternal death surveillance and review by the central government.

This role can be taken up by the Medical Colleges and independent organizations. This can also serve the purpose of monitoring of maternal death audit processes in the district. Feasibility of confidential inquiry of maternal death has already been shown.[16] These approaches will help go beyond identifying single determinant of inequity in health and understand the inter-relationship between social and structural determinants. The rapid decline in MMR neighboring Bangladesh to MDG committed levels has been attributed to factor both within and outside the health system.[17] A purposeful and concerted effort by all stakeholders and shifting focus from general to the focal nature of each maternal death will help accelerate reduction in maternal mortality. An added outcome of this approach will be a health system based on ethics of equity and universality envisaged as key policy principles in the National Health Policy 2017.



 
   References Top

1.
National Health Policy. Ministry of Health and Family Welfare. Government of India; 2017. p. 4, 11. Available Available from: www.mohfw.nic.in/documents/polic. [Last accessed on 2017 Apr 08].  Back to cited text no. 1
    
2.
NITI Aayog Release on MMR. Available Available from: http://www.niti.gov.in. [Last accessed on 2017 Apr 14].  Back to cited text no. 2
    
3.
William J, Sharma S, Sharma J, Shanta YM, Ramanathan M, Mishra US, et al. Maternal Mortality in India: A Review of Trends and Patterns. Institute of Economic Growth (IEG) Working papers no 353. 2015. p. 9, 15. Available from: http://www.iegindia.org/upload/publication/workpaper/wp353. [last accessed on 2017 Apr 12].  Back to cited text no. 3
    
4.
Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099-104.  Back to cited text no. 4
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5.
Sanneving L, Trygg N, Saxena D, Mavalankar D, Thomsen S. Inequity in India: The case of maternal and reproductive health. Glob Health Action 2013;6:19145.  Back to cited text no. 5
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6.
Vora KS, Mavalankar DV, Ramani KV, Upadhyaya M, Sharma B, Iyengar S, et al. Maternal health situation in India: A case study. J Health Popul Nutr 2009;27:184-201.  Back to cited text no. 6
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7.
Ganatra BR, Coyaji KJ, Rao VN. Too far, too little, too late: A community-based case-control study of maternal mortality in rural West Maharashtra, India. Bull World Health Organ 1998;76:591-8.  Back to cited text no. 7
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8.
Kuruvilla S, Schweitzer J, Bishai D, Chowdhury S, Caramani D, Frost L, et al. Success factors for reducing maternal and child mortality. Bull World Health Organ 2014;92:533-44B.  Back to cited text no. 8
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9.
Gil-González D, Carrasco-Portiño M, Ruiz MT. Knowledge gaps in scientific literature on maternal mortality: A systematic review. Bull World Health Organ 2006;84:903-9.  Back to cited text no. 9
    
10.
Subha Sri B, Khanna R. Dead Women Talking : A civil society report on maternal deaths in India. Common Health and Jana Swasthya Abhiyan 2014. p. 10,16-18.  Back to cited text no. 10
    
11.
Jithesh V. Social Determinants of Maternal Deaths and Maternal 'Nearmisses' in Wayanad District, Kerala: A Qualitative Study. Working Paper no. 3. Trivandrum: Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology; 2012. p. 2, 13.  Back to cited text no. 11
    
12.
Kumar S. Reducing maternal mortality in India: Policy, equity, and quality issues. Indian J Public Health 2010;54:57-64.  Back to cited text no. 12
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13.
Malhotra M. Maternal Death Review – Country Perspective: Presentation at WHO Multicountry Workshop, Bangkok, Thailand. 24-28 September, 2012. New Delhi: Deputy Commissioner, Maternal Health, MoHFW, Government of India; 2012.  Back to cited text no. 13
    
14.
Kakoty SD. Report on Surveillance of Maternal Death in Barpeta District of Assam. A Report Submitted to Srimanta Sankaradeva University of Health Sciences, Assam; 2015-16.  Back to cited text no. 14
    
15.
Padmanaban P, Raman PS, Mavalankar DV. Innovations and challenges in reducing maternal mortality in Tamil Nadu, India. J Health Popul Nutr 2009;27:202-19.  Back to cited text no. 15
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16.
Paily VP, Ambujam K, Rajasekharan Nair V, Thomas B. Confidential review of maternal deaths in Kerala: A country case study. BJOG 2014;121 Suppl 4:61-6.  Back to cited text no. 16
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17.
El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, Streatfield PK, et al. Maternal mortality in Bangladesh: A Countdown to 2015 country case study. Lancet 2014;384:1366-74.  Back to cited text no. 17
    




 

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