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Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 294-297  

Decline and disparity in maternal mortality in pre- and post-national health mission period in India

Professor, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Date of Web Publication15-Dec-2016

Correspondence Address:
Prakash Prabhakarrao Doke
Department of Community Medicine, Bharati Vidyapeeth Medical College, Satara Road, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.195857

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Country- and state-wise maternal mortality shows the highest disparity among health statistics. The erstwhile National Rural Health Mission. (NRHM) in India aimed reduction in maternal mortality ratio. (MMR) to <100 per lakh live births. Accordingly, many new initiatives were planned and started. This analysis was carried out using data from the Sample Registration System. The data from 1997 to 1998 are available which dates 8 years prior to the launching of NRHM. Hence, comparison period was considered as 8 years of implementation of NRHM. The overall decline in MMR prior to NRHM was 36% and after NRHM implementation 30%. The difference is not significant. The best states and lowest states had changed, but the disparity also has remained almost at the ratio of 1:5. The pace of decline has not increased after NRHM. As well disparity ratio has not reduced indicating the differentially better treatment to the vulnerable states was not adequate.

Keywords: Decline in maternal mortality ratio, disparity in maternal mortality ratio, maternal mortality ratio, National Rural Health Mission

How to cite this article:
Doke PP. Decline and disparity in maternal mortality in pre- and post-national health mission period in India. Indian J Public Health 2016;60:294-7

How to cite this URL:
Doke PP. Decline and disparity in maternal mortality in pre- and post-national health mission period in India. Indian J Public Health [serial online] 2016 [cited 2023 Mar 22];60:294-7. Available from:

The population of India as per 2011 census is 1210. 6 million, and India continues the position of the second most populous country in the world. It is a confederation of 36 states/union territories which have a diverse culture, geography, health infrastructure, and health indicators. Although birth and death registration is mandatory, there is gross underreporting of deaths to the extent of about 30%.[1] Sample Registration System is a sample-based robust and methodical system providing reliable vital statistics in India. The system does not include maternal mortality in the yearly statistical report, but it periodically provides through special reports; maternal mortality estimates for only larger 15 states and that too pertaining to the unspilt status. Recently, Annual Health Surveys in nine states are providing maternal mortality estimates even for cluster of districts.[2] In India, reliable information about maternal mortality is made available from the year 1997 onward by Sample Registration System.[3],[4],[5],[6],[7] The latest available information pertains to 2011–2013 period.

Reduction in maternal mortality has already been declared as one of the goals in most of the international and national policy documents including Millennium Development Goals. In India, reduction of maternal mortality ratio (MMR) to <100 per lakh live births was aimed in National Rural Health Mission (NRHM) and 11th Five-Year Plan. Nonachievement of the target compelled Government of India to continue the aim at the same level in renamed National Health Mission and 12th Five-Year Plan.

This analysis of the secondary data was carried out to compare the pace of decline and interstate disparity of MMR pre- and post-NRHM period. This analysis was carried out using available data from serial reports of the Sample Registration System on maternal mortality.[3],[4],[5],[6],[7] A comparison was made between 8 calendar years prior to the implementation of NRHM (1997–2004; both years inclusive) and 8 calendar years after implementation of NRHM (2005–2012; both years inclusive). The difference between the state having the lowest figure and the state having the highest figure was calculated for the initial year (1997) and last (2004) year of the pre-NRHM period to estimate disparity ratio (ratio of lowest and highest figure). Similar procedure was used for post-NRHM period (2004 and 2012). The decline during the period was expressed as percentage decline over the starting year. The decline in points per year was calculated by dividing total decline by seven. Similar state-wise exercise was done pre- and post-NRHM period. Investigator considered four states having lowest and highest values in 1997, 2004, 2005, and 2012 and fifth Maharashtra State (where he works) for interstate comparison.[3],[4],[5],[6],[7] For the evaluation of pace of decline, Chi-square test for trend was applied to before and after the study periods. For comparison, the global data were obtained from the reports of the World Health Organization. The available estimates from various countries at the time of launching of NRHM and recent data were also analyzed.

Indian scenario of state-wise MMR range and disparity emerged from successive reports of SRS is shown in [Table 1]. Earlier in 1997–1998, the range was 131–606 (475). Recently, during 2011–2013 MMR has been reduced and ranges from 61 to 300 (239). However, the disparity ratio has almost remained same at about 1:4.75 (1:4.6 and 1:4.9).
Table 1: Decline in maternal mortality ratio, India

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Review of the global level at the time of launching of NRHM (2005) reveals that Ireland had the lowest MMR of 1 per lakh live births, whereas Sierra Leone had MMR of 2100 per lakh live births.[8] In the year 2005, MMR was high in many countries. In the year 2005, the disparity ratio was 1:2100 and range was also identical. Probably, the disparity in MMR in 2005 may be the highest disparity observed in health indicators among countries. In 2013, Belarus had the lowest MMR of 1 per lakh live births, and Sierra Leone continued to have the highest MMR of 1100 per lakh live births.[9] The ratio of disparity as well the range of MMR in 2013 has been reduced to 1:1100. Although the disparity was still high in 2013, there is some improvement both in MMR and disparity. At the global level, high range is anticipated. In 1997–1998 SRS report, Gujarat was shown to have least MMR of only 46, but subsequent reports had shown high MMR and the first figure had been ignored in [Table 1]. The range between the absolute figure of highest and lowest MMR among the states has certainly decreased although disparity ratio has not decreased. This general inference remains valid though the estimates from the latest SRS and Annual Health Survey in nine states are not concordant.[10] The strategies such as proclamation of Empowered Action Group states, differential payment in Janani Suraksha Yojana, and better monitoring through estimating divisional MMR by carrying out Annual Health Surveys are formulated and executed to decline the overall ratio as well to minimize the gap between the highest and lowest states. Continuing the same disparity ratio indicates that differential attention paid toward low performing states is suboptimal. Some additional differential strategies giving more attention toward states having high MMR are certainly needed.

The observed decline for 8 years before and after NRHM and subsequent forecasting is given in [Figure 1] using forecasting function available in Excel. The data show that decline in MMR had already good pace even before launching of NRHM. The actual decline in points per year and percentage decline pre-NRHM period (1997–2004) and at the end of the implementation of first phase of NRHM (2005–2012) in five states is given in [Table 1]. The linear trend in India as per [Figure 1] was similar before and after NRHM (χ[2] = 0.00; P > 0.10). In the first report of Maternal Mortality in India by SRS, considering the rate of decline existing then, it was forecasted that by 2012, MMR would be reduced to about 231.[3] The trend based on a log-linear model for the period 1997–2012 from the first SRS report is reproduced in [Figure 1]. Now, the precise estimate for 2012 is available which shows MMR in India is 167. It is a good indication that the overall strategies executed have defied the initial forecast and yielded a better result for this 16 years period. The Reproductive and Child Health program was started in 1997, which is the initial year of data analysis in the present study. India did not achieve the targeted reduction of achieving MMR 100 per lakh live births in the 11th plan. Current statistical forecasting based on observed MMR in SRS reports as given in [Figure 1] predicts that India may achieve the goal of MMR <100 per lakh live births somewhere in 2016. The decline may be faster and once again defy the forecast as a result of continuous attention being given to maternal health by better implementation of existing programs and introducing appropriate new schemes.
Figure 1: Maternal mortality ratio trend in India

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The state-wise scenario is varied; some states such as Maharashtra, Assam, and Tamil Nadu showed the faster decline after NRHM and in some states like Kerala, the decline was faster before NRHM and Uttar Pradesh a mixed picture. In Kerala and Tamil Nadu, only small improvement in MMR was expected; whereas in Assam and Uttar Pradesh, profound improvement was expected. Materialization of this expectation would decrease the disparity ratio. Overall in India, the decline was faster before NRHM. The difference in decline between pre- and post-NRHM period was not significant denoting that certainly the pace has not been accelerated. NRHM was very ambitious program from the beginning. It has completed the first phase of 7 years of implementation in 2012. Normally, the argument may come forward that tackling hardcore factors such as blood transfusion facilities and availability of Cesarean section are difficult and hence the decline may not be very fast. Under NRHM, following new activities such as Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram, Maternal and Child Tracking System, Maternal Child Health wings, and Maternal Death Review were initiated. For tackling specific causes of maternal death, following provisions have been given priority after NRHM launching; provision of comprehensive abortion care, provision of misoprostol, and provision of MgSO4 were also emphasized. Training for capacity building in identified aspects like Basic Emergency Obstetric Care and Comprehensive Emergency Obstetric Care training for doctors for 10 days and 16 weeks (6 weeks institutional and additional 10 weeks hands on), respectively, has been started. Skilled Birth Attendant training is imparted for 2–3 weeks for General Nurse Midwives and 3–6 weeks for Auxiliary Nurse Midwives. Life-Saving Anesthetic Skills for Emergency Obstetric Care training is imparted to MBBS doctors for 24–26 weeks. The core intention of these activities under NRHM was to address various hardcore factors and achieve desired reduction at an accelerated pace.

The conclusion indicates that expected perceivable results in increasing pace of decline as well reducing disparity in MMR in pre- and post-NRHM period are not observed. The reasons could be 3-fold. First, longer time may be required to observe significantly accelerated declining pace in trend. Many activities such as JSSK and MCTS were initiated in the later period of the first phase of NRHM. Second, the implementation of all these initiatives has occurred variedly across the states. Third, although population perceived needs like institutional deliveries have increased, the rate of prevention of maternal deaths has not increased proportionately. Probably, it means that the reasons are at the health-care institutional level like suboptimal availability and practice of comprehensive emergency obstetrics services in vulnerable areas. Many countries even in the Southeast Asia such as Thailand, Philippines, and Sri Lanka have already achieved far better MMR than India. All these countries became independent at about the time as India. Review and critical analysis of causal factors is seriously needed to match these countries.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Office of Registrar General, India. Ministry of Home Affairs, Vital Statistics Division. Vital Statistics of India Based on the Civil Registration System; 2012. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 1
Office of the Registrar General and Census Commissioner, India. Ministry of Home Affairs, Government of India. Annual Health Survey 2012-2013, Fact Sheet. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 2
Registrar General, India, New Delhi in Collaboration with Centre for Global Health Research University of Toronto, Canada. Sample Registration System. Maternal Mortality in India: 1997-2003 Trends, Causes and Risk Factors; 2006. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 3
Office of Registrar General, India. Sample Registration System. Special Bulletin on Maternal Mortality in India 2004-2006; 2009. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 4
Office of Registrar General, India. Sample Registration System. Special Bulletin on Maternal Mortality in India 2007-2009; 2011. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 5
Office of Registrar General, India. Sample Registration System. Special Bulletin on Maternal Mortality in India 2010-2012; 2013. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 6
Office of Registrar General, India. Sample Registration System. Special Bulletin on Maternal Mortality in India 2011-2013; 2015. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 7
World Health Organization. Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA, and the World Bank; 2007. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 8
World Health Organization. Trends in Maternal Mortality: 1900 to 2013: Estimates by WHO, UNICEF, UNFPA, The World Bank and United Nations Population Division; 2014. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 9
National Health Mission. Ministry of Health and Family Welfare, Government India. Available from: [Last accessed on 2015 Aug 08].  Back to cited text no. 10


  [Figure 1]

  [Table 1]

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