Maternal mortality in India: The true killers
Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
Seth GS Medical College and King Edward Memorial Hospital, Mumbai
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Salvi V. Maternal mortality in India: The true killers.J Postgrad Med 2009;55:1-2
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Salvi V. Maternal mortality in India: The true killers. J Postgrad Med [serial online] 2009 [cited 2021 Oct 26 ];55:1-2
Available from: https://www.jpgmonline.com/text.asp?2009/55/1/1/48433
This issue of the journal carries reports , from two teaching hospitals in Mumbai on autopsy findings in maternal mortalities. Though India, based on a sample registration system, reported its Maternal Mortality Rate (MMR) as being 301/100,000 live births, the WHO in its adjusted MMR estimation has pegged it at 450/100,000 live births.  The WHO has based its correction on the fact that there is limited evidence of the completeness of the coverage of maternal deaths. Why do so many Indian women die due to pregnancy and its complications every year? India's MMR is in stark comparison to that of the US and UK, which is 11 and 8, respectively. The lifetime risk of maternal death in an Indian woman is 1 in 70 as compared to 1 in 8200 in the UK and 1 in 4800 in the US. Comparing India with the only other country that approaches its population in magnitude, the MMR in China is 45 with a lifetime risk of maternal death being just 1 in 1300.
The Millennium Development Goals (MDG) laid down by the United Nations aim for a reduction in maternal deaths by 75% between 1990 and 2015.  At the global level, maternal mortality has decreased at an average of less than 1% annually between 1990 and 2005 - far below the required 5.5% that is necessary to achieve the MDG goals.  It is estimated that 117,000 Indian women die annually during pregnancy, childbirth and the puerperium. The country has the dubious distinction of having the highest number of maternal deaths worldwide and accounts for one-fifth of all global maternal mortalities.  Clearly, MMR in India will need to decrease at a much faster rate in the future and this goal needs to be achieved by giving priority to women and their healthcare.
The dismal picture with respect to maternal mortalities in India is seen despite the fact that the country is progressing on many fronts. The growth in GDP (Gross Domestic Product) during 2007-08 is estimated at 8.7%. It is likely that during 2007-08, the per capita income in real terms (at 1999-2000 prices) will have attained a level of Rs. 24,256 as compared to the Quick Estimate for the year 2006-07 of Rs 22,553.  Indians today have a life expectancy of 64 years (estimate for year 2006) as compared to 49 years in 1970;  53.7% of Indian women (as compared to 75.3% males) are literate.  On the reproductive health front too there has been some progress.  Fifty-two per cent of Indian mothers had in the last pregnancy, at least three antenatal visits, and 76.3% mothers had received the basic tetanus toxoid immunization during pregnancy.
Why then does the country still lag behind with respect to saving maternal lives?
The National Family Health Survey-3(NFHS-3)  is the third large-scale multi-round survey which has been conducted throughout India in all 29 states in a representative sample of households. This survey has two specific goals: to provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and program-related purposes; and to provide information on important emerging health and family welfare issues. NFHS-3 has determined that as many as 48% of pregnant women still do not achieve three antenatal visits in pregnancy.  Only 23.1% mothers received iron and folic acid for at least 90 days in the last pregnancy. Anemia is widespread in Indian women (56.2%)  and this coupled with malnutrition (33% women have a body mass index below normal  ) ensures that a large number of Indian women conceive when they are not fit to undertake a pregnancy. While only 40.7% women had an institutional delivery, 48.2% women had their birth assisted by a doctor, nurse, LHV/ ANM (lady health visitor/ auxiliary nurse midwife) or other health personnel.  Thus, more than half of India's mothers deliver without the assistance of any health personnel. These are only some of the reasons we have not been able to ensure their safety. Moreover, considering the fact that approximately 28 million Indian women become pregnant every year,  the number of women whose health is endangered is prodigious.
The Indian population still grows at a whopping 1.578% per year.  All the advances made on every front are simply negated by the burgeoning population which is also unfortunately extremely poor. It is deplorable that even today, 300 million Indians are classified as being below the poverty line.  What is even more deplorable is that the poverty line in India has been pegged by the government at an abysmal low of Rs 296 per month for urban areas and Rs. 276 per month for rural areas i.e. daily earnings of less than Rs. 10 per day.  This amounts to Rs. 3650 per year or US $ 75 per year. On the other hand the World Bank defines the poverty line for underdeveloped countries as earnings less than US$1/day/person or US $365 per year. As per this definition, probably more than 75% of all Indians are below the poverty line. 
From the NFHS-3,  it is evident that 44.5% of Indian women have been married before the legal age of marriage. A staggering 71.6% of these women are illiterate. Child marriage is relatively low (12.8%) only in those women who have benefited of at least 10 years of education. Early marriage is associated with early childbirth and as many as 16% of the females aged 15-19 were already mothers or pregnant at the time of the survey. The advantage of education is reflected in the fact that median age at first birth was 18.7 years in uneducated women as compared to 23.6 years in women who had availed of at least 10 years of education. Pregnancy and childbirth are leading causes of death in teenage girls in developing countries and the risk of maternal mortality is much higher in child mothers. 
Early marriage has been a tradition in many parts of India. Many Indians consider that ensuring an early marriage for their children is a part of their duty towards one's family and a matter of status.  This practice continues in spite of the fact that the legal age at marriage in India is 18 years for girls and 21 for boys which is far higher than that of many other countries.  The fact that many Indian women are ignorant of this legal requirement  ensures that uneducated and poor Indians continue with the practice of early marriage with its attendant disastrous complications.
It is probable that the vicious triad of poverty, illiteracy and early marriage fuels the population explosion in India with 28 million pregnancies annually; half of these pregnancies lack medical supervision. This then translates into an extremely high maternal mortality. Policy makers in India are aware of all these facts and the further action that is necessary to change this gloomy scenario. It needs willpower to sustain committed efforts to ensure that all Indians receive higher education with its attendant improvement in social status. Only such a change has the possibility of ensuring that Indians will marry at a later age and couples will be able to exercise their right to conceive as per their choice and have the number of children they desire and that women will have their pregnancies monitored appropriately and be assured of a safe delivery.
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