On Thursday, when The Indian Express reported how the country’s maternal mortality ratio had come down from 167 per 100,000 live births in 2011-13 to 130 in 2014-16, another report described how a tribal woman in labour in Kerala was carried on a sling made of clothes for want of a road. While Kerala leads in most health indices, including MMR, what the woman went through underlines how these indices are often held hostage to physical infrastructure such as roads. And while India has made sustained progress in reducing maternal mortality, it missed the millennium development goal (MDG) of reducing MMR by 75% from 437 in 1990 to 109 in 2015.
In 2010, an article in the Indian Journal of Public Health by the chief UNICEF officer in Chennai was critical of India’s likely failure to meet the MDG, yet spoke favourably of initiatives under the National Rural Health Mission, which was launched in 2005 to develop rural health infrastructure. “Under NRHM, one of the main strategies or policy shifts to reduce maternal mortality is Janani Suraksh Yojna (JSY) — a conditional cash transfer scheme to motivate pregnant women for institutional deliveries. In better developed states of South India, the cash incentive however is limited to women below poverty line up to first two childbirths… It is well known that maternal mortality steeply rises in grand multiparous women delivering a child after third pregnancy onward. A few state governments… with a high MMR… have judiciously modified the guidelines to implement the scheme and included all women irrespective of their parity or economic status,” the article said.
With JSY, institutional births doubled from 38.7% to 78.9% between National Family Health Survey III (2005-06) and NFHS IV. In addition, the web-based Mother and Tracking System headquartered in the National Institute of Health and Family Welfare, New Delhi, tracked every pregnancy in the country since 2010, sending out messages to health workers and expectant mothers about ante-natal checkups, vaccinations etc.
NRHM also allowed auxiliary nurse midwives (ANMs) to administer antibiotics, intravenous fluids and drugs during emergencies under supervision. For Ceasarean sections, there are first referral units (FRUs). “We took a three-pronged strategy on MMR — first was to improve institutional deliveries and SoPs, increase the frequency of visits by ASHAs and attend to women who were not going to hospitals for deliveries. The basic issue was of improving standards. We devised the incentive system of ASHAs in such a way that they got good money only if they visited throughout the nine months… What added to all of this was the nutritional support from anganwadis. States also upped their game, many FRUs were set up,” said Environment Secretary C K Mishra who, as Health Secretary, oversaw these initiatives.
Another programme was Janani Shishu Suraksha Karyakram (JSSK) that entitles all pregnant women delivering in public health institutions to free delivery, including C-sections. In a Mann ki Baat programme in 2016, Prime Minister Narendra Modi appealed to private hospitals to devote one day of the month for check-ups of pregnant women. Under the Pradhan Mantri Surakshit Matritva Abhiyan, pregnant women can walk into private establishments on the 9th of the month.
In 2015, an article in The BMJ said: “While some states like Maharashtra, Tamil Nadu and Andhra Pradesh were able to bring down maternal mortality rate even lower than stipulated ratio; many others were marginally off by the target. Sadly, states like Assam, UP, Rajasthan, MP and Bihar showed dismissive reports.” This time, these were the states that spearheaded the MMR reduction.