Reducing Maternal Mortality in India

Digvijay Singh


The estimates of the present decade show that worldwide each year nearly half a million women die from complications during pregnancy and childbirth. About 99% of these women belong to the developing world with over 90% concentrated in Africa and Asia. The current maternal mortality ratio (MMR) in India is 301/100,000 live births. [1] The tragedy is that these deaths are largely preventable. For every woman who dies, approximately 30 more incur injuries, infection, and disabilities which are debilitating, humiliating, and usually remain untreated and unspoken of. The risk of a woman dying as a result of pregnancy and childbirth during her lifetime is about 1 in 6 in Afghanistan compared with 1 in 30,000 in Northern Europe. [2] Such a discrepancy and inequity in distribution, access, and outcome of maternal care services poses a huge challenge to meeting the fifth Millennium Development Goal (MDG-5) to reduce maternal mortality by 75% between 1990 and 2015. Preventable maternal deaths indicate gross violation of the basic human right of survival and highlight gross failure of health services on almost all fronts particularly in terms of choice of strategic interventions and their extent of coverage in population.

The progress in maternal health has been uneven, inequitable, and unsatisfactory. UN’s report card on MDG-5 concluded that little progress had been made in sub-Saharan Africa where half of all maternal deaths take place. The progress shown by the South Asian countries including India which accounts for 25% of all maternal deaths is also not impressive. [3] However, countries like Sri Lanka, Thailand, Egypt, Honduras, and Bangladesh have demonstrated perceptible reduction in maternal mortality (by 40-70%) by making appropriate strategic choices and collective action. Even within India, states like Tamil Nadu and Kerala have made impressive efforts to reduce maternal mortality in poor resource settings. These examples raise hopes that it is possible to bring about favorable changes and optimally reduce maternal mortality and reach the fifth MDG in India.

Global reviews and studies reveal that maternal deaths are clustered around labor, delivery, and the immediate postpartum period with obstetric hemorrhage being the main medical cause of death. [4] Local variations can be important with unsafe abortions carrying huge risks in a few African and Asian countries including India (where 13% of maternal deaths are due to unsafe abortions). In addition, HIV and malaria further contribute significantly to maternal mortality in Africa.

In view of the above, it is most relevant and interesting to briefly review the evolution of maternal care and strengths and weaknesses of Public Health Care services to reduce maternal mortality in India.

Earliest attempts in maternal health in the preindependent India were most appropriately placed on improving safe midwifery skills and assistance during childbirth. This is evidenced by the establishment of a “Dai’s” (midwifery) school in Amritsar in 1880, passing of the first Midwifery Act in London in 1902, and setting up of the Advisory Committee on Maternal Mortality in 1937 by the India Research Fund (now called Indian Council of Medical Research). Thus, the policy focus of health services for maternal care was to provide safe midwifery practices including abortions and a careful review of maternal mortalities occurring in hospitals to prevent avoidable deaths. It may not be an exaggeration to say that the health professionals and planners in the preindependent India correctly identified what works to reduce maternal mortality. However, this focus on safe motherhood and skilled assistance during childbirth was lost in the models of the health care delivery system that we adopted in free India based on the recommendations of famous “Bhore Committee (1946)” to begin with. Even today there is no formal policy requirement in many states in India to carry out regular and systematic reviews of maternal deaths occurring in large numbers in various district- and subdistricts-level hospitals. It is useful to look at a few key developments and landmarks in the health care delivery system in rural India with a favorable and or not so favorable influence on maternal care.

Following the recommendations of the “Bhore Committee Report,” [5] the Government of India set up three-tier health care delivery system to reach out to remote areas to provide primary care at a village level, secondary care at a subdistrict and district level, and tertiary care at a regional level. Medical colleges and specialist care centers were developed as “apex institutions.” During the last 50 years, India has greatly expanded the public health infrastructure to include more than 1,44,000 subcenters (SCs) each covering a population of about 5000, 22,600 primary health centers (PHCs) (for a population of 30,000), 4000 community health centers (CHCs) (for 100,000-300,000 population) and 242 medical college hospitals (for a 5-8 million population). [6] A large proportion of these SCs, PHCs, and CHCs are not fully equipped and competent to provide quality midwifery care or deal with complications of pregnancy and childbirth. The Srivastava Committee [7] in 1975 (Group on Medical Education and Support Manpower) recommended the development of a viable referral system complex linking PHCs and district hospitals to medical colleges and apex institutes. The committee also recommended an integrated teaching program for Pediatrics, Obstetrics, and Community Medicine relevant to the health needs of the community and thus called for the reorientation of medical education. Owing to deficient political and administrative support and lack of commitment from the teaching faculty of medical colleges, the recommendations of the committee could not be fully implemented and sustained in field.

SCs were set up to provide maternity care at the most peripheral level and auxiliary nurse midwives (ANMs) were appointed to run SCs under supervision of trained nurses. Majority of ANMs did not have required knowledge and skills to provide maternity care and support and supervision they received from their supervisors (trained nurses and later on by lady health visitors and medical officers) was highly deficient and irregular. ANMs continued to provide community-based maternal care till 1975 when the multipurpose worker (MPW) scheme was introduced based on the recommendations of the Kartar Singh Committee (report of the committee on MPWs under Health and Family Planning Programme, 1973). This policy change further deteriorated the quality and coverage of maternal care. ANMs’ job responsibilities now got expanded to include primary health care and disease control activities. A second policy change in 1977 integrated maternal and child health (MCH) and family planning renaming it, “family welfare.” These two policy changes resulted in a drastic decline in the quality of the ANMs’ training program in the country especially with regard to their midwifery skills and practices. Under pressure from the Government, the Indian Nursing Council (INC) [8] revised the ANM training course and reduced its duration from 24 months to 18 months. In the field, the community perception of ANMs changed from a maternal care worker to family planning and immunization worker during mid-1970s and 1980s. The maternal mortality ratio in India did not show any perceptible decline from 1970 to 1990.

It was only in 1992 that the Government of India expanded the scope of Universal Immunization Program (UIP) and converted it into Child Survival and Safe Motherhood Program (CSSM) by incorporating the elements of safe motherhood interventions. [9] These were in terms of setting up of “First Referral Units (FRUs): and blood storage units at a subdistrict level to provide Emergency Obstetric and Referral Care. The CSSM program was a good policy shift to address maternal mortality by focusing at safe motherhood and delivery care. However, this program was transformed into Reproductive and Child Health (RCH) program to include additional elements of care like treatment of reproductive tract infection and sexually transmitted diseases, recruitment of additional ANM at selected PHC to provide 24-h delivery services, provision of funds to local governing bodies for referral transport, and training of medical officers to upgrade their skills in Obstetric Care and Obstetric Anesthesia. The first phase of the RCH program was of 7-year duration (1997-2004). The program moved into the second phase in 2005 and was placed under an ambitious initiative of the Government of India called National Rural Health Mission (NRHM). [10] The latter is being run in a mission mode by an independent directorate and in many states the RCH program is yet to become fully integrated and convergent with NRHM. Similarly, National AIDS Control Organization runs the Prevention of Parent to Child Transmission of HIV program (PPTCT) in a vertical manner without much integration with the RCH directorate (or with NRHM) although both programs focus on pregnant mothers and newborns. 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 (or second parity). It is well known that maternal mortality steeply rises in grand multiparous women delivering a child after third pregnancy onward. A few state governments (in Empowered Action Group States) with a high MMR in population have judiciously modified the guidelines to implement the scheme and included all women irrespective of their parity or economic status. [11] The NRHM has also led to policy changes to allow ANMs to administer antibiotics and intravenous fluids and oxytocic drugs and initiate management of obstetric emergencies under supervision. It also endorses and encourages 16-week training of medical officers in Obstetric Anesthesia thus empowering them to administer anesthesia and facilitate conduction of C-sections in first referral units (FRUs). Many FRUs are not fully operational in our country for want of anesthetists. NRHM has also laid emphasis on establishing blood storage unit, and upgrading CHCs, FRUs, and district hospitals for providing Comprehensive Emergency Obstetric Care (CEMOC). The mission tends to adopt a convergent, multisectoral approach involving development sectors like sanitation, water supply, elementary education, and rural development to improve public health situation in the country and places heavy reliance on Panchayat Raj Institution (PRI). States where PRIs are not energized or empowered may not fully meet the expectations of NRHM.

MDGs and maternal care in India

The MDGs are eight goals to be achieved by 2015 that respond to the world’s main development challenges. The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations and signed by 147 heads of state and governments during the UN Millennium Summit in September 2000.

MDG-5 stands for improving maternal health and aims at reducing the MMR by 75% between 1990 and 2015. For India, the target is to achieve an MMR of 108 by 2015.

Maternal care in India

Overall progress in extending the outreach of maternal care and reduction in maternal mortality in India has been uneven, inequitable, and unsatisfactory. However, a few states in south India (Tamil Nadu and Kerala) have shown perceptible progress by making the right strategic choice of promoting skilled birth attendance and enabling policy environment. The remarkable achievement of almost 100% institutional delivery and an MMR of 95 in Kerala and 111/100,000 live births in Tamil Nadu provides evidence that the fifth MDG can be achieved and its vision transformed into reality in other states as well.

At the country level, the MMR declined from 301 in 2004 to 254 in 2006. The MMR in India ranges from 480 in Assam to 95 in Kerala [1] (SRS, 2004-2006). Keeping in view the overall pace of decline in the MMR, it seems unlikely that India would achieve MDG-5 by reducing the MMR level to 108 by 2015. India is among 51 slow progressing nations in maternal and child care. There are two indicators defined to monitor progress toward achieving targets under MDG-5: (1) MMR and (2) institutional delivery. [3]

Other maternal care indicators

The coverage of family welfare program needs to be further improved as evidenced by a poor contraceptive prevalence rate of 56% and unmet contraceptive need of 13% in eligible population groups (NFHS-3). [12] The total fertility rate stands at 2.9 which contributes to increased lifetime risk of maternal deaths. The unmet contraceptive need results in unwanted pregnancies. It is no wonder to record that 13% of maternal deaths in India are still attributed to unsafe abortions. Medical Termination of Pregnancy (MTP) Act was passed in the country way back in 1971 but all PHCs and FRUs are not equipped to carry out MTP. Even in states like Tamil Nadu, unsafe abortions account for 4-6% of all maternal deaths. [7]

More than half of pregnant women in India (52%) receive three or more antenatal care visits and about three-fourths of them (72%) receive one antenatal visit by any health worker. About two-thirds of pregnant women (65%) receive iron and folic acid (IFA) tablets under the anemia prophylaxis program but only one-fourth consume them for the recommended duration of 90 days. [12] A study conducted in Uttar Pradesh in 2008 indicated that only 66% pregnant women received IFA tablets, 19% received full courses of 100 tablets, and only 15% consumed 100 tablets during their pregnancy cycle. [13]

Obstetric care

Institutional deliveries and delivery by skilled attendants have shown uprising trends in India during the period between NFHS-2 (1994-1996) and NFHS-3 (2005-2006). Institutional delivery rose from 34% to 41% and deliveries assisted by skilled health professionals from 42% to 49% during the period under NHFS-2 and NFHS-3.

Postnatal care

Only 37% of mothers received postnatal care within 40 h of childbirth. Poor coverage of postnatal care is a serious concern as a large proportion of maternal deaths are concentrated during the early postpartum period (NFHS-3). [12]

Quality and equity issues in maternal care

It is clear from the above description that maternal care services in India leave much to be desired in terms of coverage and contents of care. Poor quality of maternal care remains a cause for grave concerns in face of rapid expansion of health care infrastructure. We have today in our country 370 district hospitals, 1762 FRUs, 4045 CHCs, and 23,370 PHCs. [6]

The quality of services extended by the health care centers and hospitals is greatly compromised due to deficiency of skilled manpower. A total of 30% of FRUs and 50% of CHCs do not have anesthetists and the same numbers do not have obstetricians. The quality and coverage of Emergency Obstetric Care (EMOC) is thus adversely affected in many parts of the country. As mentioned earlier, there has been tremendous expansion of health care infrastructure in rural India over the last four decades. However, there is no system for accrediting health care facilities or evaluating functioning of health facilities at state or national level. Over half of the existing subcenters (55%) and 30% of PHCs do not have their own buildings. Over 70% of FRUs and CHCs do not have linkages with a district blood bank. [8] The general duty medical officer, if posted at FRUs or CHCs, tries to refer all obstetric emergencies to the next higher level, even though these could be managed locally at the first reporting site. The inclusion of doctors under Indian Consumer Protection Act has taken away whatever little incentive that is left to them in terms of professional satisfaction to carry out obstetric first-aid procedures. [4]

Quality of maternal care offered by a facility is very much dependent upon the resources available (equipments, drugs, skilled manpower) and adherence to predefined criteria for delivery of services. Not many large scale observation studies are available on the assessment of antenatal, natal, and postnatal care. An attempt was made by UNICEF team to assess the quality of obstetric care at subdistrict and district hospitals on pilot basis while carrying out strategic analysis of the health system in four states following Marginal Budgeting for Bottleneck (MBB) tools. MBB is a result-based planning and budgeting methodology and has also been used to build a strategic framework for reaching health-related MDGs in sub-Saharan Africa. The framework was developed jointly by UNICEF, WHO, and the World Bank with recent support and inputs from UNFPA. For analysis of health systems and identification of system-wide demand and supply “bottlenecks” in Orissa and Tamil Nadu, the study [14] employed direct observation, record analysis, and interviews with service providers as main tools of data collection. The maternal and child care was assessed using predefined criteria under different heads like availability, accessibility, utilization, adequate coverage and effective coverage. The quality of care is reflected by the effective coverage (care delivered by a knowledgeable provider adhering to standard norms). Only 2% of health facilities in Orissa could provide effective obstetric and sick newborn care. In Tamil Nadu, however, the effective coverage of skilled birth attendance (as measured by the active management of third stage of labor), emergency obstetric care, and postnatal care (as measured by postnatal care infection prevention intervention) is around 50%.

Three delays in seeking maternal care

In most instances, women who die in childbirth are found to have experienced at least one of the following three delays.

The first delay is the delay in deciding to seek care for an obstetric complication and occurs mostly at the household level. The second delay occurs after the decision to seek care has been taken and occurs in transporting the patient from home to the health facility. The third delay is the delay in obtaining care at the facility. This is one of the most tragic issues affecting maternal survival and is a direct reflection of quality and concern with which the health facility offers emergency obstetric care to the patient. A verbal autopsy tool – Maternal and Perinatal Death Inquiry and Response (MAPEDIR) – was used to elicit information on above-mentioned three delays and the cost involved in seeking care. MAPEDIR is a tested method of finding out the medical causes of death and ascertaining the personal, family, or community factor that may have contributed to the death of a pregnant woman. The findings are based on conducting this inquiry by the UNICEF team in the Purulia district of West Bengal and analyzing 102 maternal deaths (from July 2005 to June 2006) of the district. [15]

It was found out that the time taken to decide to seek care and arrange for transport from home to the facility was around 4-5 h for most mothers. Yet, any woman having postpartum hemorrhage would survive only for a maximum of 2 h. At the referral level in both first and second referral facilities, most cases were attended within 5 min (0-7 h). Most families spent around Rs. 500 at the first facility and more than Rs.1400 at the second facility.

The above description clearly indicates that the quality of maternal care remains unsatisfactory. This is largely on account of deficient resources in terms of skilled human resources, referral linkage, and noncompliance with the standard treatment protocols. The Government should allocate resources to upgrade PHCs, FRUs, blood storage facilities, and district hospitals. Effective coverage of obstetric care (skilled birth attendance and emergency obstetric care) which indicates satisfactory quality of care was around 50% even in most progressive states with a low MMR like Kerala and Tamil Nadu. Effective coverage of obstetric care was much lower in states like Orissa and Chhattisgarh. [14]There is a strong need to upgrade the obstetric care skills of medical officers and nurses. Competency-based training programs should be carried out and standard protocols for the management of obstetric complications should be adopted by the apex institutes and medical colleges and should form an integral part of their teaching curricula.

Maternal care – equity issues

Maternal mortality and maternal health care scenario globally brings to surface glaring disparities and inequities. Maternal deaths are concentrated in poor and disadvantaged women in different countries of the world. MAPEDIR using the verbal autopsy tool to analyze maternal deaths in India revealed that 80% of maternal deaths occurred in poor families with minimal facilities; 61% of mothers who died were from the lower caste, that is, 37% from the Scheduled Castes (SC) and 24% from the Scheduled Tribes (ST). [15]

Findings of NFHS-3 (2004-2006) reveal that the coverage of antenatal care was less in SC (74%) and ST (70.6%) compared to other population groups (84.8%). Similarly, the outreach of skilled attendants at birth was much less in ST (25.4%) and SC (40.6%) women compared to others (57.8%). The percentage of institutional deliveries was much less in ST (17.7%) and SC (32.9%) compared to others (51%). Besides the SC/ST population group, the economic status of women is also a key determinant of access to care. This is true for India as well as for many other countries in the world. This is clear from the NFHS-3 report where critical items of obstetric care like skilled birth attendance, intuitional delivery services, or postnatal care are distributed preferentially in favor of rich population groups (richest wealth quintiles). [12] In south Asian and sub-Saharan countries, less than 40% of poor people received skilled attendance at delivery (up to third wealth quintile) compared to around 60% or more for rich women of these countries. In India, for example, only 12% of poor women had their deliveries conducted in hospitals compared to 82% belonging to the higher economic group. [12] When it comes to accessing institutions for emergency obstetric care, the cost involved in the transport of patients, purchase of drugs, etc. becomes a prohibitive factor. Verbal autopsy of maternal deaths in the Purulia district of West Bengal (2005-2006) indicated that most of the families spent Rs. 500 for transporting patients to the first referral facility and around Rs. 1400 to the second referral facility. [15] Even after spending a large amount of money in second referral facilities families lost women during or after childbirth.

Health expenditure by the government

The Government must allocate higher resources to the health budget and improve first referral units – quantitatively and qualitatively. In poor and developing countries, we find low spending on health by governments and very high health care expenditure by people (out-of-pocket), in private sectors. In India, for example, governments spend less than 1% of GDP on health. This has meant that a disproportionately large and growing share of the burden of health care had been borne by households in India, such that they account for an increasing share of total expenditure (nearly three quarter). Unlike many other countries, this is completely in the form of out-of-pocket expenses, which are inherently regressive. [16] Also the share of household consumption expenditure devoted to health care has also been increasing overtime, especially in rural areas where it now accounts for nearly 7% of the household budget on average. It becomes very clear that high “out-of-pocket” expenses and the absence of social protection like wide health insurance coverage have exacerbated the vulnerability of the poor and prohibits poor people to seek timely medical or health care.

It is notable that India has the lowest ratio of public-to-private health expenditure among most countries of the world including poorest countries. Further, all the private expenditure in India (as in some other countries) constitutes of out-of-pocket expenses.

What is more alarming is the reduced per capita spending on public health in almost all the states in India. Only Maharashtra, Tamil Nadu, Kerala, and West Bengal show some increase. Most dramatic decline in spending is seen in the case of Madhya Pradesh and Uttar Pradesh.

Expenditure by states on health is not proportionate to the health needs of the state. States with high infant and maternal mortality spend less money per capita on health compared to states with lower mortality rates (Uttar Pradesh Rs. 48.2, Tamil Nadu Rs. 122, Kerala Rs. 128, and Madhya Pradesh Rs.35.90). [16]

We also note that the absorption capacity of the states with high MMR or IMR is poor. About 50% of funds allocated under National Rural Health Mission were spent in 2007. Government expenditure is not well targeted on the poor. The coverage gap for many maternal care interventions (antenatal, skilled births attendance, postnatal care) was about two to three times larger among the poorest than the least poor quintiles. In recent years, however the Government is sharpening its focus on improving access to maternal and health care by poor. Janani Suraksha Yojna, a maternity benefit scheme of the Central Government, is essentially a conditional cash transfer scheme that has tremendously improved institutional delivery coverage among poor, SC, and ST.

Dr. Muthulakshmi Reddy Scheme of the Government of Tamil Nadu again is a maternity benefit scheme targeting women below poverty line. Under the scheme, Rs.6000 is given to women to support her nutrition and referral transport during pregnancy, childbirth, and in the postnatal period. [17]

Equity issues in service delivery

Biases in service delivery in the form of skewed investments of resources and infrastructure result in intradistrict inequities in health provision. A study using Indian district-level data on determinants of health and education services revealed religion and caste as important determinants. [18] The spatial geography of exclusion with the SC group inhabiting smaller hamlets away from the main village and ST groups inhabiting remote forest terrains also results in exclusion via neglect and nonparticipating approaches to development. A report on persistence of untouchability in rural India showed that 30-40% of Dalit villages surveyed reported denial of visits by health workers, 20-25% villages reported denial of entry into private health clinics, and 10-15% villages reported discriminatory treatment in PHCs. [18] Where frontline service providers like ANMs are drawn from upper castes, there are reports of discrimination against Dalit women.

On track to achieve maternal mortality reduction target (MDG-5) – a case study of maternal care in Tamil Nadu state

It is very encouraging to note that a few states in India have shown remarkable progress in reducing maternal mortality by introducing innovative changes within the framework of existing organizational set-up, resources, and constraints. Overarching political priority and constituent policies of the successive state governments to reduce maternal mortality has been a guiding force. Tamil Nadu has recorded impressive achievements in reducing MMR over a period of last few decades. As per NFHS-3, [12] overall indicators of MCH care are also very encouraging like low infant mortality rate (31/1000 livebirths), high child immunization coverage (81%), high contraceptive prevalence (61.6%), high antenatal care coverage (3 antenatal visits – 96.5%), and institutional deliveries (96%). The key strategy to reduce MMR is focused at ensuring 100% institutional delivery and quality emergency obstetric services (both basic and comprehensive) at PHCs, FRUs, and district hospitals. [17] The state government follows a threefold path to success as described below:

Prevention and termination of unwanted pregnancies: Through successful implementation of the family welfare program, Tamil Nadu has achieved a demographic transition toward the replacement level of fertility. The total fertility rate (TFR) stands at 1.7 in 2005 (a decline from 2.0 in 2000) and the crude birth rate (CBR) at 16 in 2008 (declined from 19.3 in 2000). The unmet need for Family Welfare Services in Tamil Nadu declined from 13% (1998-1999) to 9% (2005-2006). However, 6% of maternal deaths in Tamil Nadu still occur due to lack of access to MTP services.

Promoting institutional deliveries and quality emergency obstetric care: Institutional delivery is promoted as a state policy. The public information campaigns of NRHM and the mass media inform the public and build a positive image of government health institutions and advantages of seeking hospital care during childbirth. Tamil Nadu government has special schemes for pregnant women (from below poverty line) to promote institutional deliveries. Under Muthulakshmi Reddy Maternal Assistance Scheme, the State Government provides cash assistance of Rs. 6000 to each pregnant woman to compensate for loss of wages and pay for nutrition supplementation. This scheme is running in Tamil Nadu in addition to the Government of India cash assistance scheme of “Janani Suraksha Yojana” to promote skilled attendance during childbirth for pregnant women (below poverty line) (Rs. 600 and Rs. 700, respectively, for institutional deliveries in rural and urban area). The institutional delivery coverage in Tamil Nadu is 96% (2009).

Interventions to shorten the three delays: The PHCs in Tamil Nadu are equipped to provide 24-h obstetric care services. Upgraded and block PHCs provide Basic Obstetric and Newborn Care (BEmONC) services along with Prevention of Parent to Child HIV transmission (PPTCT) services. In order to reduce the second delay, the State Government has collaborated with NGOs and private sector to set up an emergency referral transport system. Referral control rooms have been set up in all districts to give the public access to timely ambulance transportation to health services. People in need of ambulance services call the control room on telephone helpline that has the same number, throughout the state.

In order to reduce the third delay, the State government has taken the following initiatives:

Upgrade two to three strategically located FRUs in each district to comprehensive 24-h Emergency Obstetric and Newborn Care (CEmONC) centers. Around 62 such centers are established (10 teaching hospitals and 52 FRUs). These centers are equipped with blood banks or blood storage units and surgical operation facilities (for C-Section).
The shortage of anesthesiologists has been addressed by permitting the health facilities to contract private anesthesiologists and by conducting short-term training for medical officers on Obstetric Anesthesia.
Surveillance and investigation of maternal deaths : Tamil Nadu initiated identification and compulsory reporting of maternal deaths in 1994. The efficiency of reporting has improved over time. By 2001, almost all maternal deaths were being reported. Two types of maternal deaths audit are done – the institution-based maternal death audit and the verbal autopsy. In the former only maternal deaths occurring in the institution are reviewed to find out the causes of death and related factors. The latter covers all deaths – institutional and domiciliary. The protocols for operationalizing the verbal autopsy also include “district maternal deaths verbal autopsy” meetings convened by the District Collectors every month in their districts to review maternal deaths.

All the above-mentioned initiatives by the government of Tamil Nadu have led to drastic reduction in all types of delays and consequently a reduction in maternal mortality in Tamil Nadu. A total of 70% women reach PHCs directly to seek obstetric care of who one-third belong to the underprivileged category. Reduction in type-3 delay is borne out by the fact that 83% women received recommended obstetric care within half an hour of admission to the referral facility. The MMR in Tamil Nadu has thus shown a persistent decline from 132 in 2001-2003 to 111 in 2004-2006.


1. Timing of maternal deaths is clustered around labor, delivery, and immediate postpartum period. Therefore, a health center, intrapartum care strategy would be most likely to bring down MMR. This could be in terms of a focus on promoting institutional deliveries supported by round-the-clock comprehensive emergency obstetric transport facilities.
2. A link between poverty and maternal deaths has been clear. The Government and public health sector cannot be absolved of their responsibilities to prevent these deaths by providing essential maternal and newborn care services of an acceptable quality. The Central and state governments must allocate higher resources to the provision of public health care including MCH services.
3. Statistics on maternal deaths should not b allowed to slip into easy usage. For every maternal death, there are at least 20 other women who survive with disabilities associated with social stigma and humiliations which no statistics can capture. We need to bring about a societal momentum to transform the “silent emergency” of maternal deaths into a war cry for ensuring basic human rights for survival and social justice for women.


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Sures KK. Reaching Health related MDGs in India. State Specific Strategic Analysis in Tamil Nadu and Orissa. Unpublished data with UNICEF Office for Tamil Nadu and Kerala, Chennai Nov 2008.

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Shah G. Untouchability in Rural India. 2006 quoted by Suresh K. in Reaching Health related MDGs in India. State Specific Strategic Analysis in Tamil Nadu and Orissa. Unpublished data with UNICEF Office for Tamil Nadu and Kerala, Chennai Nov 2008.

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