reduction-of-maternal-mortality-ratio-mmr-in-india-pib

Context: The Maternal Mortality Ratio (MMR) in India has declined to 113 in 2016-18 from 122 in 2015-17 and 130 in 2014-2016, as per the latest Special Bulletin on MMR released by the Registrar General of India.

Analysis

  • In simple terms, the MMR is defined as the number of maternal deaths per 1,00,000 live births. 
  • The MMR of various States according to the bulletin includes Assam (215), Uttar Pradesh (197), Madhya Pradesh (173), Rajasthan (164), Chhattisgarh (159), Odisha (150), Bihar (149), and Uttarakhand (99). 
  • The southern States registered a lower MMR — Andhra Pradesh (65), Telangana (63), Karnataka (92), Kerala (43) and Tamil Nadu (60). 
  • Eleven states have already achieved the ambitious target of MMR of 100 per lakh live births by 2020 set under the National Health Policy 2017. 
  • These states are Kerala, Maharashtra, Tamil Nadu, Andhra Pradesh, Jharkhand, Telangana, Gujarat, Uttarakhand, West Bengal, Karnataka and Haryana. 
  • This has been possible in view of the gains made in institutional deliveries and focused approach towards aspirational districts and inter-sectoral action to reach the most marginalised and vulnerable mothers.
  • Seven states — Karnataka, Maharashtra, Kerala, West Bengal, Odisha, Rajasthan, Telangana — have shown decline in MMR that is greater than or equal to the national average of 6.2%.
  • The target 3.1 of Sustainable Development Goals (SDG) set by the United Nations aims to reduce the global maternal mortality ratio to less than 70 per 1,00,000 live births.
  • With this persistent decline, India is on track to achieving the Sustainable Development Goal (SDG) target for reducing MMR by 2025, five years ahead of timeline of 2030.
  • However, the four states namely Assam, Uttar Pradesh, Madhya Pradesh and Rajasthan will have to intensify their efforts to accelerate the MMR decline to achieve the SDG target. 
  • The WHO last year lauded India’s progress in reducing the MMR saying the progress puts the country on track towards achieving the Sustainable Development Goal (SDG) target of an MMR below 70 by 2030 (Please note the States who have already achieved this target as well).
  • Under MDG 5, India had committed to reducing maternal mortality to 108 deaths per 100,000 live births by 2015. 
  • However, only three states—Kerala with an MMR of 66 per 100,000 live births, Tamil Nadu with an MMR of 90 and Maharashtra with an MMR of 87—had been able to achieve the millennium development goal before the deadline.
  • To understand the maternal mortality situation in the country better and to map the changes, especially at the regional level, the government has categorised states into three groups: empowered action group (EAG), southern States and other states.
  • Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh/Uttarakhand and Assam fall under the EAG.
  • Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu are in the southern States group. 
  • “Others” comprise the remaining States and Union Territories.

What is Maternal Mortality Ratio and who measures it?

  • The maternal mortality ratio is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births.
  • The Office of the Registrar General of India (ORGI) under the Ministry of Home Affairs, Government of India provides estimates of Maternal Mortality Ratio (MMR) using demographic data collected through the Sample Registration System (SRS).

Development goal

  • Focus on quality and coverage of health services through public health initiatives under the National Health Mission such as LaQshya, Poshan Abhiyan, Pradhan Mantri Surakshit Matritva Abhiyan, Janani Shishu Suraksha Karyakram, Janani Suraksha Yojana and Pradhan Mantri Matru Vandana Yojana have contributed to this decline.
  • India is now committed to ensuring that not a single mother or newborn dies due to a preventable cause and move towards zero preventable maternal and newborn deaths through the recently launched Surakshit Matritva Aashwasan Initiative (SUMAN), Ministry of Health and Family Welfare. 
  • The Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) was launched in 2016 by the Ministry of Health and Family Welfare to ensure comprehensive and quality antenatal checkups to pregnant women across India. 
  • Pregnant women, mothers up to 6 months after delivery, and all sick newborns will be able to avail free healthcare benefits. 
  • Under the scheme there will be zero expense access to identification and management of complications during and after the pregnancy. 
  • The government will also provide free transport from home to health institutions. 
  • The pregnant women will have a zero expense delivery and C-section facility in case of complications at public health facilities.
  • The PMSMA has reached one crore mark with the commitment from doctors in the government sector across States/ UTs and with the help of the large number of private sector doctors who have voluntarily pledged for this initiative. 
  • Under the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), with the objective to provide quality Ante Natal Care (ANC) to every pregnant woman, a fixed day ANCs given 9th day of every month across the country. 
  • This is to be given in addition of the routine ANC at the health facility.
  • India has also launched Mother and Child Tracking System, through which expecting mothers and health workers are tracked and informed about vaccinations and health checks, and Kilkari project, a mobile voice message service that delivers weekly messages to families about pregnancy, family planning, nutrition, childbirth and maternal and child care.

LaQshya (Labour Room Quality Improvement Initiative)

  • After launch of the National Health Mission (NHM), there has been substantial increase in the number of institutional deliveries. 
  • However, this increase in the numbers has not resulted into commensurate improvements in the key maternal and new-born health indicators. 
  • It is estimated that approximately 46% maternal deaths, over 40% stillbirths and 40% newborn deaths take place on the day of the delivery.
  • A transformational change in the processes related to the care during the delivery, which essentially relates to intrapartum and immediate postpartum care, is required to achieve tangible results within short period of time.
  • ‘LaQshya’ programme of the Ministry of Health and Family Welfare aims at improving quality of care in labour room and maternity Operation Theatre (OT) and to enhance satisfaction of beneficiaries visiting the health facilities and provide Respectful Maternity Care (RMC) to all pregnant women attending the public health facility.
  • The Scheme also involves the presence of Birth companion during delivery.
  • The Quality Improvement in labour room and maternity OT will be assessed through NQAS (National Quality Assurance Standards). 
  • Every facility achieving 70% score on NQAS will be certified as LaQshya certified facility. 

Janani Shishu Suraksha Karyakaram (JSSK)

  • Ministry of Health and Family Welfare (MoHFW) has launched the Janani Shishu Suraksha Karyakaram (JSSK) in 2011. 
  • The initiative entitles all pregnant women delivering in public health institutions in both rural and urban areas 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 wherever 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.
  • The scheme aims to eliminate out of pocket expenses incurred by the pregnant women and sick new borne while accessing services at Government health facilities.
  • The scheme is estimated to benefit more than 12 million pregnant women who access Government health facilities for their delivery. 
  • Moreover, it will motivate those who still choose to deliver at their homes to opt for institutional deliveries.
  • All the States and UTs have initiated implementation of the scheme.

Janani Suraksha Yojana (JSY)

  • Janani Suraksha Yojana (JSY), Ministry of Health and Family Welfare, a demand promotion and conditional cash transfer scheme, is a safe motherhood intervention under the National Rural Health Mission (NHM). 
  • It is being implemented with the objective of reducing maternal and infant mortality by promoting institutional delivery among pregnant women. 
  • The scheme is under implementation in all states and Union Territories (UTs), with a special focus on Low Performing States (LPS).
  • Janani Suraksha Yojana was launched in April 2005 by modifying the National Maternity Benefit Scheme (NMBS). 
  • When JSY was launched the uniform financial assistance was replaced by graded/differential scale of assistance based on the categorization of States as well as whether beneficiary was from rural/urban area. 
  • States were classified into Low Performing States and High Performing States on the basis of institutional delivery rate i.e. states having institutional delivery 25% or less were termed as Low Performing States (LPS) and those which have institutional delivery rate more than 25% were classified as High Performing States (HPS). 

Target Group and benefits

  • The scheme focuses on poor pregnant woman with a special dispensation for states that have low institutional delivery rates, namely, the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. 
  • While these states have been named Low Performing States (LPS), the remaining states have been named High Performing states (HPS).
  • The scheme also provides performance-based incentives to women health volunteers known as ASHA (Accredited Social Health Activist) for promoting institutional delivery among pregnant women. 
  • Under this initiative, eligible pregnant women are entitled to get JSY benefit directly into their bank accounts. 
  • In both LPS & HPS, BPL/SC/ST women are entitled for cash assistance in accredited private institutions. 
  • Exclusion criteria of age of mother as 19 years or above and up to two children only for home and institutional deliveries under the JSY have been removed and eligible mothers are entitled to JSY benefit regardless of any age and any number of children. 
  • The Yojana enables the States/UTs to hire the services of a private specialist to conduct Caesarean Section or for the management of Obstetric complications, in the Public Health facilities, where Government specialists are not in place.
  • States are encouraged to accredit private health facilities for increasing the choice of delivery care institutions. 

Cash assistance for home delivery

  • BPL pregnant women, who prefer to deliver at home, are also entitled to a cash assistance of Rs. 500 per delivery regardless of the age of pregnant women and number of children.

Pradhan Mantri Matru Vandana Yojana (PMMVY)

  • It has been launched by the Ministry of Woman and Child Development. 
  • Under the scheme, pregnant women and lactating mothers are offered a cash incentive of ₹6,000 for the birth of their first child as partial compensation for wage loss, to reduce maternal mortality and malnutrition levels among children. 
  • Cash incentive of Rs 5000 is provided in three instalments i.e. first instalment of Rs 1000/ - on early registration of pregnancy at the Anganwadi Centre (AWC) / approved Health facility, second instalment of Rs 2000/ - after six months of pregnancy on receiving at least one ante-natal check-up (ANC) and third instalment of Rs 2000/ - after child birth is registered and the child has received the first cycle of BCG, OPV, DPT and Hepatitis - B, or its equivalent/ substitute.
  • The eligible beneficiaries would receive the incentive given under the Janani Suraksha Yojana (JSY) for Institutional delivery and the incentive received under JSY would be accounted towards maternity benefits so that on an average a woman gets Rs 6000/-. 
  • Under the National Food Security Act, 2013, all pregnant women (except those already receiving similar benefits under other laws) are entitled to maternity benefits of ₹6,000 per child.
  • In this context, the modalities of the scheme violate the NFSA: benefits are restricted to the first living child, and to ₹5,000 per woman.
  • The Scheme covers all Pregnant Women and Lactating Mothers, excluding those who are in regular employment with the Central Government or the State Governments or PSUs or those who are in receipt of similar benefits under any law for the time being in force.
  • In case of miscarriage/still birth, the beneficiary would be eligible to claim the remaining instalment(s) in event of any future pregnancy.
  • In case of infant mortality, she will not be eligible for claiming benefits under the scheme, if she has already received all the instalments of the maternity benefit under PMMVY earlier.
  • The scheme will provide Aadhaar linked, Direct Benefit Transfer in beneficiary’s bank/post office account in three instalments 
  • at the stage of early registration of pregnancy, 
  • after six months of pregnancy on at least one antenatal check-up and
  • registration of child birth & first cycle of immunisation of the child.
  • The PMMVY is Centrally Sponsored Scheme under which the cost sharing ratio between the Centre and the States & UTs with Legislature is 60:40, for North-Eastern States & three Himalayan States, it is 90:10 and 100?ntral assistance for Union Territories without Legislature.
  • The States are bound to implement this Scheme because the scheme is a by-product of the National Food Security Act.

PMMVY has been able to reach less than a third of the eligible beneficiaries

  • A vital programme to support lactating mothers and pregnant women by compensating them for loss of wages during their pregnancy has been able to reach less than a third of the eligible beneficiaries, researchers who extrapolated from data obtained under the Right to Information (RTI) Act said.

Causes

  • Several factors impeded proper implementation of the programme that aims to fight malnutrition among children. 
  • First, the coverage and benefits were reduced (compared with NFSA norms, which are very modest in the first place). This defused public demand for PMMVY. Had the benefits been higher and universal, the scheme would have been a hit. 
  • Second, the application process is tedious. Aside from filling a long form for each instalment, women have to submit a series of documents, including their ‘mother-and-child protection’ card, bank passbook, Aadhaar card and husband’s Aadhaar card. Essential details in different documents have to match, and the bank account needs to be linked with Aadhaar. 
  • Third, there are frequent technical glitches in the online application and payment process. When an application is rejected, or returned with queries, the applicant may or may not get to know about it. Grievance redressal facilities are virtually non-existent.
  • Odisha, which decided to not implement PMMVY because it has its own State-sponsored scheme called ‘Mamata’ that includes two births, has a few lessons to offer through its near universal coverage. 
  • The infant mortality rate among tribals is the fourth highest in Odisha, after Madhya Pradesh, Rajasthan and Chhattisgarh. 

Causes for dissatisfaction among beneficiaries of PMMVY

  • One in three Aadhaar-based payments for the Centre’s maternity benefit scheme, or Pradhan Mantri Matru Vandana Yojana (PMMVY), was credited to a wrong bank account, according to a progress report on Poshan Abhiyaan (Nutrition Mission) released by the NITI Aayog.
  • A substantial number of payments (28% of all Aadhaar-based payments) are going to different bank accounts than what had been provided by the beneficiaries. It is a prime cause for dissatisfaction among beneficiaries.
  • Under the PMMVY, pregnant women and lactating mothers receive ₹5,000 for their first child in three instalments. 
  • Each tranche is released upon the beneficiaries meeting some conditions. 
  • The money is meant to compensate women for loss of wages, and is aimed at ensuring a healthy nutritional development of the newborn.
  • The NITI Aayog has called for “simplification in documentation and operational rules” to avoid delays. 
  • It has proposed to “rationalise” the mandatory waiting period of 180 days before the second instalment is released as well as the compulsory birth certificate for the release of the third instalment. 
  • It calls for the training of auxiliary midwives who fill up the mother-child protection card, which is among the documents needed to get the benefit, and data entry operators so that application details are entered online and payments and complaints are processed on time.

Other initiatives 

  • Maternal Death Surveillance and Response (MDSR) is implemented to take corrective action for averting maternal deaths. 
  • Mother and Child Tracking System (MCTS) and Mother and Child Tracking Facilitation Centre (MCTFC), a name-based web-enabled system to track every pregnant women and child.

Do you know?

  • Maternal Mortality Ratio (MMR) refers to the number of maternal deaths per 100,000 women of reproductive age in a year.
  • Child Mortality Rate (CMR) refers to the number of deaths of children less than 5 years of age per 1000 live births.
  • Infant Mortality Rate (IMR) refers to the number of deaths of children less than one year of age per 1000 live births.
  • Neo natal Mortality Rate refers to the number of deaths of children less than 28 days per 1000 live births.
  • Peri-natal Mortality Rate refers to the sum total of neo-natal death and foetal deaths (still births) per 1000 live births.