India grapples with high maternal death rate

Mon Jan 26, 2009 6:29am IST

PURULIA, India (Reuters) - In Sindri village in a dirt-poor district of eastern India, Manohar Kumbhakar and his family are still mourning the death of his wife, who died in childbirth aged 25 while being treated by a local quack.

"I don't know what he did to my daughter-in-law. The quack kept me outside the room and later, after almost two hours, he said she had to be taken to a hospital," said Kumbhakar's mother, Helubala. "He later denied he had any role in the treatment."

Every year, about 78,000 mothers die in childbirth and from complications of pregnancy in India, according to the United Nations Children's Fund (UNICEF).

The figures illustrate how poor women in rural India have largely been left behind by India's economic boom which has lifted millions of people out of poverty.

India's maternal mortality rate stands at 450 per 100,000 live births, against 540 in 1998-1999. The figures are way behind India's Millennium Development Goals which call for a reduction to 109 by 2015, according to UNICEF.

By comparison, fellow Asian giant China's maternal mortality rate has dropped to below 50.

UNICEF's 2009 State of the World's Children report, which was released in January, said India's fight to lower maternal mortality rates is failing due to growing social inequalities and shortages in primary healthcare facilities.

Millions of births are not attended by doctors, nurses or trained midwives, despite India's booming economy which grew at nearly 9 percent in each of the past three years.

Around two-thirds of Indian women still deliver babies at home. Women from the lower castes suffer the most as they are often denied access to basic healthcare.

"It (the maternal mortality rate) is definitely not going down fast enough," Avinash Kumar, Campaign and Policy Coordinator for Oxfam India, told Reuters.


Traditional midwives such as 50-year-old Chapa Sahis are often the only help available for women in labour in remote areas. UNICEF and local authorities offer dais proper training, but Sahis' qualifications are minimal.

"I am not a doctor or even a trained nurse. I have some training to cut the cord with a blade. A doctor can always save many mothers," she says.

Maternal deaths are avoidable with the help of skilled health personnel, adequate nutrition, better medical facilities and family planning, medical groups say.

But poor women, especially in rural India where fertility rates are higher and teenage marriages are common, face an uphill battle to overcome lack of access to medical care.

Indian women get married at a median age of just 17 years. Among women aged 15-19, 16 percent have already begun childbearing, according to the 2005-2006 National Family Health Survey (NFHS).

"The younger a girl is when she becomes pregnant, the greater the health risk for herself and baby," said Ann M. Veneman, UNICEF's executive director.

UNICEF said nearly half the women who die during pregnancy and childbirth in Purulia, in West Bengal, have no formal schooling.

"Women get pregnant very early with no preparedness to cope with childbirth, at times failing to recognise the signs when they should go to a hospital," said Alpana Mahato, a local nurse.

Women are often sent home prematurely from health facilities, or do not visit them because of a view that the woman was not sick enough to justify the trip, said UNICEF. When they do go, women in labour sometimes face extortion.

"We have found health centre staff in Uttar Pradesh demanding money from poor women for delivery. Many were turned away from the centres and were forced to give birth on the road or the hospital compound," said Jashodhara Dasgupta of Health Watch, a network of activists.

Women's food intake across South Asia must improve if the region's high maternal mortality rate is to drop. More than half of Indian women have anaemia, another potential killer during childbirth, compared to 24 percent of men, the NFHS study said.

"Nutrition and anaemia are huge factors in the MMR (maternal mortality rate)," UNICEF's Kumar said. "Inside the homes, women are the last to get food. They are much more vulnerable and that is why they are dying."

For Your Ready Reference:

Maternal Mortality definition
According to the WHO, "A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."

Generally there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or their management, and an indirect maternal death that is a pregnancy-related death in a patient with a preexisting or newly developed health problem. Other fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

Maternal mortality is a sentinel event to assess the quality of a health care system. However, a number of issues need to be recognized. First of all, the WHO definition is one of many; other definitions may also include accidental and incidental causes. Cases with "incidental causes" include deaths secondary to violence against women that may be related to the pregnancy and be affected by the socioeconomic and cultural environment. Also, it has been reported that about 10% of maternal deaths may occur late, that is after 42 days after a termination or delivery, thus, some definitions extend the time period of observation to one year after the end of the gestation. Further, it is well recognized that maternal mortality numbers are often significantly underreported .

Reducing the maternal mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 -Improving Maternal Health - of the eight Millenium Development Goals; its progress is monitored here.

Maternal Mortality Ratio (MMR)
Maternal Mortality Ratio is the ratio of the number of maternal deaths per 100,000 live births. The MMR is used as a measure of the quality of a health care system. Sierra Leone has the highest maternal death rate at 2,000, and Afghanistan has the second highest maternal death rate at 1900 maternal deaths per 100,000 live births, reported by the UN based on 2000 figures. According to the Central Asia Health Review, Afghanistan's maternal mortality rate was 1,600 in 2007.[7] Lowest rates included Iceland at 0 per 100,000 and Austria at 4 per 100,000. In the United States, the maternal death rate was 11 maternal deaths per 100,000 live births in 2005.[8]

"Lifetime risk of maternal death" accounts for number of pregnancies and risk. In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for developed nations only 1 in 2,800.

In 2003, the WHO, UNICEF and UNFPA produced a report with statistics gathered from 2000. The world average per 100,000 was 400, the average for developed regions was 20, and for developing regions 440. The worst countries were: Sierra Leone (2,000), Afghanistan (1,900), Malawi (1,800), Angola (1,700), Niger (1,600), Tanzania (1,500), Rwanda (1,400), Mali (1,200), Somalia, Zimbabwe, Chad, Central African Republic, Guinea Bissau (1,100 each), Mozambique, Burkina Faso, Burundi, and Mauritania (1,000 each).

Maternal mortality ratio (per 100 000 live births)

Rationale for use

Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also a MDG indicator.

Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduced: Pregnancy-related death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life - e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born.
Definition of Maternal mortality rate
Maternal mortality rate: The number of maternal deaths related to childbearing divided by the number of live births (or by the number of live births + fetal deaths) in that year.