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MATERNAL MORTALITY AND

ROLE PLAYED BY MIDWIVES
Any health or health related problem which affects a vast majority of people and hampers the progress of an
area or nation or which damages normal lifestyle of people and moreover which is preventable at least to a
certain extent, can be called a public health problem. In India, Maternal Mortality Rate has become a major
public health problem. MMR is defined as death of a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by
pregnancy or its management but not from accidental or incidental causes.

Present Situation
The right to survive pregnancy and childbirth is a basic human right. Under international law, the government
of India bears a legal obligation to ensure that women do not die or suffer complications as a result of
preventable pregnancy-related causes. The staggering scale and continuing occurrence of maternal deaths and
morbidity in India reveals the governments failure to protect womens reproductive rights, and comply with
international law.
But the present situation of India has been described as below:
India has recorded a decline in maternal mortality rates between 1990 and 2013 but along with Nigeria
it accounted for one third of the global maternal deaths.

According to World Health Organizations Trends in maternal mortality estimates 1990 to 2013, an
estimated 289,000 women died in 2013 from complications in pregnancy and childbirth, down from
523,000 in 1990.

Although the MMR dropped but, India is far behind the target of 103 deaths per live births to be achieved
by 2015 under the United Nations-mandated Millennium Development Goals (MDGs).

The MMR in southern states fell 17% from 127 to 105, closer to the MDGs. Assam and Uttar Pradesh/
Uttarakhand were the worst performing states, with an MMR of 328 and 292, respectively. Kerala and
Tamil Nadu have surpassed the MDG with an MMR of 66 and 90, respectively.

According to the Annual Health Survey (AHS), which covers nine states, India has made headway in
institutionalizing child deliveries, i.e., taking place in hospitals. More than 40% of child deliveries in
Chhattisgarh and 79% in Madhya Pradesh were institutional in 2012, compared with 34.9% in Chhattisgarh
and 76.1% in Madhya Pradesh in 2011.

The states covered by the AHS are Rajasthan, Uttarakhand, Uttar Pradesh, Madhya Pradesh, Bihar,
Jharkhand, Chhattisgarh, Odisha and Assam.

More than 85% of the total births took place in government institutions in Madhya Pradesh and Odisha
in 2011, and this was more than 60% in the other states surveyed, except Jharkhand, according to the
latest AHS data.

Total fertility ratio (TFR), or the average number of children given birth by a woman, reach a preferred
level of 2.1 in only 29 out of 284 AHS districts, whereas in 2011 it was 20 districts, according to the AHS
data.

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Causes of High MMR in India

Medical Causes

The most common direct medical causes of maternal death around the world are hemorrhage, obstructed
labor, infection (sepsis) and hypertensive disorders related to pregnancy, such as eclampsia. These conditions
are largely preventable and once detected, they are treatable.

Complications from unsafe abortion are another common and preventable direct cause of maternal death.
The NFHS-3 and other studies confirm the widespread prevalence of these causes of maternal mortality
in India.

In India as well as globally, a significant portion of maternal deaths are ascribed to indirect causes.
Indirect causes are those conditions or diseases that can lead to complications in pregnancy or which
are aggravated by pregnancy. In India, common indirect causes of maternal death are anemia, malaria
and HIV/AIDS. Anemia and unsafe abortion are deserving of special note, as these two causes of maternal
death are more common in India than they are in much of the world. The percentage of maternal deaths
caused by hemorrhage is greater in India than in the rest of the world and has been attributed to higher
rates of anemia in Indian women. Pregnant women who are anemic, face multiple health risks in addition
to the risk of maternal death. Anemic women are increasingly susceptible to communicable diseases such
as tuberculosis (TB) and malaria, which are associated with adverse outcomes during and after pregnancy.
Anemic women face the further risk of falling into a cycle of multiple pregnancies in their efforts to have
children that survive, since nutritional deficiencies during pregnancy notably reduce the chances of infant
survival. In India, anemia is far more prevalent in women than in men, with the NFHS-3 reporting that
55% of women have anemia, as compared to only 24% of men.

Complications from unsafe abortion account for a significant proportion of maternal deaths in India.
According to the government, around 9% of total maternal deaths are caused by unsafe abortion,but
medical experts put the figure at almost 18%; higher than the global average of 13%. Although abortion
is legally permitted on several grounds, each year approximately 6.7 million abortions occur outside of
government-recognized health centers, often in unhygienic conditions or by untrained abortion providers.
This problem disproportionately affects adolescents, as unsafe abortions account for half of all maternal
deaths of women aged 15-19. Most women in India are not able to obtain legal abortions for multiple
reasons, including a dearth of information about safe abortion services; inconsistent and prohibitive costs;
a shortage of trained providers and adequate equipment; lack of confidentiality and informal demands for
spousal consent; poor access to facilities; and lack of knowledge about the legal status of abortion one
study showed that only 9% of Indian women knew that abortion was legal.

Socioeconomic factors
A higher incidence of mortality and morbidity is found to occur among woman and girls who are poor
or low-income, less educated and belong to socially disadvantaged castes and tribes.

Child marriage puts young girls and adolescents at significant risk of pregnancy-related complications and
mortality.

Pregnant women living with HIV/AIDS experience an increased risk of pregnancy-related fatalities due to
outright discrimination.

The affordability of reproductive health services for women is a major concern. The burden of high outof-pocket expenses for reproductive health care has been identified as a leading cause of poor reproductive

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health outcomes among low-income women in South Asian countries, including India. This trend may be
attributed to the fact that the government spends less than 1% of its Gross Domestic Product (GDP) on
health which in turn has led to insufficient access to health care services and poor quality of care.
Consequently, hospitalization is frequently a cause of debt among the poor, which in turn leads to increased
poverty. In terms of barriers faced specifically by poor women to maternal health care, studies point to
their increased likelihood of receiving a lower quality of care than rich women, which serves as a deterrent
against seeking institutional health care, leading to higher risk of pregnancy-related complications and
mortality. Consequently, in India, the poorest women have significantly less access to antenatal health care
than rich women.

Education level has been noted by experts as one of the most important indicators of womens status
related to maternal mortality, in light of its affects on fertility rates and access to employment and health
care. Female education and female literacy rates are strongly correlated to high rates of maternal mortality
around the world. Some national-level comparisons show that literacy is a stronger predictor of maternal
health than economic wealth. Lack of education adversely affects womens health by limiting their knowledge
about nutrition, birth spacing and contraception. This is particularly evident in India, where a womans
level of education strongly correlates to many indices of maternal health, including fertility rate, utilization
of prenatal care, met need for contraception and higher age at first birth. Furthermore, studies in India
show that education level is a key determinant of the quality of care received by women in health care
settings, and that illiterate women tend to experience significantly lower interpersonal quality of care in
health facilities.

Health-System Related Factors

Essential reproductive health services are not available to the majority of women in India. The National
Human Rights Commission (NHRC) reports that a mere 30% of the population receives services through
the public health system. The unavailability of basic reproductive health services including contraceptives,
pre- and post-natal care and emergency obstetric care, as well as delays in seeking institutional care and
the poor quality of care provided in government hospitals, have contributed dramatically to maternal
deaths.

High maternal mortality rates correlate strongly with inadequate access to family planning information and
services. Unwanted pregnancies expose women to significant risks to their maternal health, including
complications from unsafe abortions and high-risk pregnancies. Studies show that women facing unwanted
pregnancies are far more likely to seek induced abortions, including illegal abortions, and are much less
likely to receive adequate pre-natal care.

Less than 50% of women give birth with the assistance of a skilled attendant and only 40% of deliveries
occur in an institutional setting. Although the WHO recommends that women receive four antenatal
checkups during pregnancyand the Indian government has promised to ensure that women are provided
four checkups through the NRHM, less than three-quarters of women in India receive any antenatal
examination at all. Access to maternal health care varies greatly by state. In West Bengal over 90% of
women receive at least one prenatal examination, while in Bihar that number is only 34%.

Most maternal deaths are attributable to the three delays: the delay in deciding to seek care, the delay
in reaching the appropriate health facility, and the delay in receiving quality care once inside an institution.
The first delay, the delay in deciding to seek care, can occur due to inadequate resources, poor access to
high-quality health care and lack of awareness at the household level of the importance of maternal health
care. The second delay refers to lack of access to obstetric care. Lack of access can mean that appropriate
facilities do not exist or are not physically accessible; or it can mean that financial, socio-cultural or

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infrastructural barriers such as impassable roads or lack of transportation options prohibit women from
promptly gaining access to an existing facility. The third delay typically results from untimely diagnosis
and treatment, poor skills and training of care providers, prolonged waiting time at the facility, shortage
of equipment and blood, multiple referrals to different health facilities, and shortages in electricity or water
supply.

Steps taken by Government

The government has launched the reproductive and Child Health Programme Phase II (RCH-II) under the
umbrella of the National Rural Health Mission (NRHM), aims to improve access for rural people, especially
poor women and children to equitable, affordable accountable and effective primary health care, with a special
focus on 18 States, with the ultimate objective of reducing Infant Mortality, Maternal Mortality and Total
Fertility Rates.
The key strategies and interventions under the NRHM for reduction of Maternal Mortality Ratio are:
Janani Suraksha Yojana (JSY), a cash benefit scheme to promote Institutional Delivery with a special focus
on Below Poverty Line (BPL) and SC/ST pregnant women;

Operationalizing round the clock facilities for delivery services in the 24X7 Primary Health Centres
(PHCs) and First Referral Units (FRUs) including District Hospitals, Sub-district Hospitals, Community
Health Centres and other institutions.

Augmenting the availability of skilled manpower thorough various skill- based trainings of Skilled Birth
Attendants; training of MBBS Doctors in Life Saving Anesthetic Skills and Emergency Obstetric Care
including Caesarean Section.

Provision of Ante-natal and Post-natal Care services including prevention and treatment of Anaemia by
supplementation with Iron and Folic Acid tablets during pregnancy and lactation.

Organizing Village Health and Nutrition Days (VHNDs) at anganwadi Centres to impart health and
nutrition education to pregnant and lactating mothers.

Systems strengthening of health facilities through flexible funds at Sub Centres (PHCs) and Community
Health Centres (CHCs) and District Hospitals.

Provision of early detection of pregnancy, regular check-up of blood pressure, hemoglobin, fetal growth
free of cost.

Regular home visit by Accredited Social Health Activist (ASHA) and sensitizing mothers about the need
of taking one extra meal, eight hours sleep at night and two hours rest at day time, early detection of
complication of pregnancy etc. ASHAs educate the mothers about the need of institutional delivery and
delivery by skilled birth attendant.

Provision of arrangement of mothers meeting every month at Anganwadi center.

Establishment of First Referral Units (FRUs) at block level having provision of normal delivery, caesarian
section and assisted vaginal delivery. FRUs are equipped with gynecologists, pediatricians, anesthetists and
blood transfusion facility.

Under Vande Mataram scheme gynecologists who are not in Governmental service, if treat pregnant ladies
at Government facilities free of cost, then they receive a particular amount of incentive from the Government
and also get Vande Mataram certificate.

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Some NGOs are working for pregnant ladies in hard to reach areas like hilly areas and delta islands like
Sundarban.

Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK). The initiative entitles all
pregnant women delivering in public health institutions to absolutely free and no expense delivery, including
caesarean section. The entitlements include free drugs and consumables, free diet up to 3 days during
normal delivery and up to 7 days for C-section, free diagnostics, and free blood whenever required. This
initiative also provides for free transport from home to institution, between facilities in case of a referral
and drop back home. Similar entitlements have been put in place for all sick newborns accessing public
health institutions for treatment till 30 days after birth. This has now been expanded to cover sick infants.

Role of Midwife in Reducing Maternal Mortality

One of the key components of the National Rural Health Mission is to provide every village in the country
with a trained female community health activist ASHA, midwives. Selected from the village itself and accountable
to it, the ASHA will be trained to work as an interface between the community and the public health system.
Following are the key components of ASHA :

They are empowered with knowledge and a drug-kit to deliver first-contact healthcare, thus every ASHA
is expected to be a fountainhead of community participation in public health programmes in her village.

ASHA is the first port of call for any health related demands of deprived sections of the population,
especially women and children, who find it difficult to access health services.

ASHA is a health activist in the community who create awareness on health and its social determinants
and mobilise the community towards local health planning and increased utilisation and accountability of
the existing health services.

She is a promoter of good health practices and will also provide a minimum package of curative care as
appropriate and feasible for that level and make timely referrals.

ASHA provide information to the community on determinants of health such as nutrition, basic sanitation
& hygienic practices, healthy living and working conditions, information on existing health services and the
need for timely utilisation of health & family welfare services.

She counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary
feeding, immunization, contraception and prevention of common infections including Reproductive Tract
Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.

ASHA mobilise the community and facilitate them in accessing health and health related services available
at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC),
Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.

She act as a depot for essential provisions being made available to all habitations like Oral Rehydration
Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills &
Condoms, etc.

Activities performed by ASHAs

Mobilizing pregnant mothers for ANC and escorting them for Institutional delivery.

Mobilizing Children & mothers for immunization.

Conducting home visits & surveys.

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DOTS Provider

Collecting blood slides.

Salt testing & water testing.

Conducting VHSC meetings.

Organizing VHND & other health activities in the village.

Motivator of family planning.

Depot holder of basic drugs.

Promoter of healthy lifestyle.

Assisting ANM in Home Deliveries.

Issues in Implementation

Corruption is widespread in providing health care facilities. The inability of pregnant woman to pay the
informal demands for money in exchange for services has been identified as a leading cause of maternal
mortality. It appears that JSY is wrongly being seen as a scheme to cover out-of-pocket costs for institutional
delivery, which is supposed to be free, rather than as a cash assistance program for nutritional and other
support. There also have been reports of ANMs selling state-provided medicines illegally and pocketing
the earnings.

Many institutions are increasing promotion of institutional delivery without first addressing or improving
the quality of care, which has led to poor services and medical care. Often institutions are not fully staffed
or do not offer services for evening births, leading to women being turned away or being sent to private
hospitals where they may incur huge medical costs. Health centers also have a lack of workable toilets
and basic sanitation facilities. Further, referral systems are weak or non-existent, leading women to be
shuttled back and forth between providers with no continuity of care.

Health workers are not adequately trained, which leads to mismanagement of delivery cases, such as the
widespread, unsupervised use of oxytocin injections before delivery.

Certain provisions of the NRHM are problematic insofar as they fail to take into account circumstances
that deny women the ability to control when, under what circumstances and how often they become
pregnant. For instance, in JSY making cash incentives conditional on consent for sterilization is a form of
coerced sterilization, as women who belong to BPL households are not likely to have the financial ability
to reject the cash payment, even if they prefer a non-permanent method of birth control. The implications
of these provisions for womens well-being and basic human rights have been overlooked by policymakers
and need to be addressed.

New Initiatives

Maternal Death Review

Notes

The process of maternal death review (MDR) has been implemented & institutionalized by all the States
as a policy since 2010. Guidelines and tools for conducting community based MDR and facility based
MDR have been provided to the States. The States are reporting deaths along with its analysis for causes
of death.

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Delivery Points (DPs)

All the States & Union Territories have identified DPs above a certain minimum benchmark of performance
to prioritize and direct resources in a focused manner to these facilities for filling the gaps like trained and
skilled human resources, infrastructure, equipments, drugs and supplies, referral transport, etc., for providing
quality & comprehensive RMNCH (Reproductive, Maternal, Neo-natal & Child Health) services.

Web Enabled Mother and Child Tracking System

Name Based Tracking of Pregnant Women and Children has been initiated by Government of India as a policy
decision to track every pregnant woman, infant & child upto 3 yrs, by name for provision of timely ANC,
Institutional Delivery, and PNC along with immunization & other related services.

A Joint MCP Card

Ministry of Health & Family Welfare and Ministry of Women and Child Development (MOWCD) has been
launched as a tool for documenting and monitoring services for ante-natal, intra-natal and post-natal care to
pregnant women, immunization and growth monitoring of infants.

Tracking of severe Anaemia during pregnancy & child birth by SCs and PHCs

Severe anemia is a major cause for pregnancy related complications that may lead to maternal deaths. Effective
monitoring of these cases by the ANM as well as the Medical Officer in charge of PHC has been started to
line list these cases and provide necessary treatment.

Technical Guidelines & Service Delivery Posters

Notes

GoI has developed & disseminated standard technical guidelines & service delivery posters for standardizing
the quality of service delivery during ANC, INC, PNC, etc from tertiary to primary level of institutions.