HAS 911: Current Status of Maternal Health in India: A Detailed Report

This report provides a critical analysis of maternal health issues in India, acknowledging the global burden of maternal deaths. It reviews India's progress in reducing Maternal Mortality Ratio (MMR) and improving maternal health from 1990 to the present, comparing it with relevant Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs). The report highlights India's significant improvements in reducing MMR since 1990, though MDGs were not fully achieved by 2015. It underscores the country's challenge in contributing to the global MMR reduction and its priorities on quality maternal care in alignment with SDGs. The report also examines the challenges faced after the implementation of programs like Janani Suraksha Yojana (JSY) and offers recommendations for India to successfully achieve the SDGs in the coming years. The report covers key indicators, achievements, strengths, and barriers in addressing maternal health issues, offering a comprehensive overview of the current status and future directions.

Running head: HAS 911 CONTEMPORARY HEALTH ISSUES
Subject: HAS911: Contemporary Issues in Public Health
Assessment 4: Report
Assessment Title: Current status of maternal health in India
Report Due Date:
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Word Count: 2,253

1HAS 911 CONTEMPORARY HEALTH ISSUES
Executive summary
The report provides a critical discussion on the issue of maternal health issues in India
recognizing global health burden due to maternal deaths in developed countries. The review of
progress of India in reducing MMR and improving maternal health is presented in the period
between 1990 till now by comparing it with relevant MDGs and SDGs for the country. The
review mainly shows that India has achieved significant improvement in reducing the MMR
since 1990, however the MDGs were not realized by 2015. India now has an unprecedented
challenge in contributing to reduction in global MMR. In preparation to achieve SDGs, India has
priorities on quality issues in maternal care and set strategies accordingly. They also focusing on
challenges faced in achieving desired outcome after the implementation of programs like JSY.
The report also presents recommendation for India to successfully achieve the SDGs in the
upcoming years.

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Table of Contents
Executive summary.........................................................................................................................1
1. Introduction..............................................................................................................................3
1.1 Issues and challenges in maternal health in India.............................................................3
1.2 Purpose and significance of the report..............................................................................3
2. Analysis of maternity health status of India................................................................................4
2.1 Discussion on relevant MDGs and SDGs..............................................................................4
2.2 Data on key indicators.......................................................................................................5
2.3 Achievement in MDGs and work towards SDGs..................................................................5
2.3 Strength and barrier of country response to the issue.......................................................7
3. Conclusion...................................................................................................................................9
4. Reference...................................................................................................................................10
5. Appendices................................................................................................................................13

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1. Introduction
Maternity health is defined as the health of women during the stage of pregnancy, child birth
and post child birth period. Although motherhood is a pleasant experience for women, however
maternal deaths have become a global burden of disease for major countries (World Health
Organization 2017). 99% of maternal deaths has been found in developing countries and issues
like infections, high blood pressure, unsafe abortion, diabetes and obstructed labor contributes to
maternal morbidity and mortality (Srivastava et al. 2013). This report is focused on analyzing
maternity health related issues for India and the key achievements of the country in achieving the
relevant Millennium Development Goals (MDGs) and the upcoming Sustainable Development
Goals (SDGs).
1.1 Issues and challenges in maternal health in India
The current challenges in maternity health in India is that rate of maternity related mortality
has increased. According to WHO (2016), five women die every year, due to child birth related
complications. On an average, 45,000 mothers are dying due to complications during child birth
every year and globally it accounts for 17% of such deaths (WHO 2016). Despite safe
motherhood policies and health promotion initiatives for women, the goal of safer maternity has
not been achieved. The proportion of death varies by geographical location, socio-cultural
diversity and female literacy. There are also the factors contributing to challenges in achieving
the MDGs (Montgomery et al. 2014).

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1.2 Purpose and significance of the report
The main purpose of this report is to review the current status of maternal health in India and
analyze recent achievement in the context MDGs and SDGs. Current status of maternal health in
India. It also provides a critical discussion on the challenges to meeting the MDGs and SDGs
2. Analysis of maternity health status of India
2.1 Discussion on relevant MDGs and SDGs
The pledge for eight Millennium Development Goals were taken by 189 nations in the year
2000 to free people from extreme poverty and achieve the eight goals by 2015. Improving
maternal health was one of the MDGs and the main goal for India was to reduce the maternal
mortality ratio (MMR) by three-fourth in the period between 1990 and 2015 (Millennium
Development Goals 2017). In the period between 1990 and 2015, several initiative was taken by
the Indian government such as launching the National Rural Health Mission in 2005 to improve
the health infrastructure of the country and achieving the target for achieving reduction in MMR
and infant mortality rates (IMR) (Gaitonde et al. 2017). In the year 2011, the Janani-Shishu
Suraksha Karyakram (JSSK) was launched which aimed to increased the access to health care for
pregnant women by providing the opportunity of institutional delivery at zero expense (Tripathi,
Saini and Prinja 2014). The purpose of all these programs was to achieve the MDGs by
improving health infrastructure and addressing the barrier to accessing health care service during
delivery. The success of such initiative has been question due to poor progress of India in
achieving the goals.
The transition from MDGs to Sustainable Development goals (SDGs) was seen after many
concerns were raised about MDGs. Some argues that environmental concerns were not addressed

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and some complained that holistic nature of development was not addressed (Fehling, Nelson
and Venkatapuram 2013). The SDGs also known as ‘Transforming our world: the 2030 agenda
for sustainable development’ is the development of 17 goals aiming to achieve a world free of
poverty, hunger and disease by the year 2030. Among the 17 goals, the issue of addressing MMR
came under the goal 3 of Good health and well being where the main purpose was to reduce the
global MMR by less than 70% per 1,00, 000 live births by 2030 and reduce neonatal mortality
rate by 12 per 1000 live births. This means India has a challenging task of reducing the maternal
mortality rate to 70 per 1000 live birth that needs to be achieved in the next 13 years (Sustainable
Development Goals 2017).
2.2 Data on key indicators
The status of maternal health is mainly defined by the indicator of maternal mortality ratio
and percentage of delivery in the presence of skilled health personnel. In addition, the universal
access to reproductive health is dependent on the indicator of contraceptive usage, antenatal care
coverage and lack of family planning. India aimed mainly to work on these indicators according
the MDGs 2015 (Hodgins, Evans and Ricca 2013). However, the desired goal in MMR could not
be achieved due to the concerns in the quality of maternal care. Currently, maternity health status
of India is poor due to variation in MMR and access to maternal health service between regions,
geographic location and socioeconomic factors. Understanding the specific factors causing
mortality and factor affecting the use of obstetric service is necessary to achieve the goal of
improved maternal health (Montgomery et al. 2014). After the implementation of different
maternity programmes following the MDGs and SDGs, there is a need to review the impact of
the program in improving pregnancy related outcomes and quality of delivery by skilled health
care professionals.

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2.3 Achievement in MDGs and work towards SDGs
In the context of achieving the MDGs goal of improving maternal health in India, the
review of progress by the end of 2015 has revealed slow progress in achieving the goal. Based on
the MDG goal, India needed to reduce maternal maternity ratio from 437 per 1, 00, 000 live birth
in 1990-1991 to 109 per 1,00,000 live births by 2015 (Millennium Development Goals 2017.
However, slow progress was found in achieving this goal. The MMR has declined to 157 per
1,00, 000 live births in 2009 and by 2015, they could achieve only 174 per 1,00, 000 births (Kaul
2017). The improvement in MMR rates in 2015 compared to 2009 was seen because of the
efforts to increase the number of trained and skilled personnel in maternity wards and
introduction of the cash transfer scheme through the Janani Suraksha scheme. Despite such
useful initiative, India could not achieve MDG of improving maternal health due to issues and
challenges in maintaining the quality of maternal care (Nath 2011).
Poor progress in quality maternal health care in India also gives the indication that
NHRM made no difference in improving the quality of maternal care. NHRM was mainly
focused on making health care accessible and affordable for the rural sections because evidence
has shown that access to obstetric service is a challenge for rural women due to financial cost
and poor literacy of women (Vora, Koblinsky and Koblinsky 2015). In response to this issue,
NHRM also integrated Janani Suraksha Yojana in their scheme to provide cash assistance to
pregnant women for continuous access to antenatal care. Although the scheme was successful in
improving the institutional delivery rate, however quality aspects were ignored. This is the main
reason for India’s poor progress in MDGs. Good quality of care in antenatal service is dependent
on client-provider interpersonal relationship. This is important to ensure satisfaction with care
and sustained use of services. However, the main limitation of Government health clinics was

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that staffs were ignorant towards patient’s perspective and this resulted in negative attitude
towards using antenatal care (Nai and Panda 2011). This might be a factor that compromised the
quality of maternal care as well as proper utilization of maternity health clinics in India.
By 2015, India managed to achieved MMR goal of 174 per 1,00, 000 births. According to
2030 SDGs, (Sustainable Development Goals 2017), India has the task of reducing the global
MMR. To towards SDGs, India has to focus mainly on people living in vulnerable situations and
addressing nutritional needs of pregnant and lactating women. The status of MMR in 2013 was
190 and after the implementation of the 12th national health plan, the target was to reduce MMR
to 75 by 2017. SDG has an unprecedented scope and in preparation towards MDGs, India is
planning to build robust health system and strengthen primary care provided in rural and urban
areas. Due the barrier in achieving MDGs due to several barriers in quality maternal care, India
also developed a strong system for monitoring, evaluation and accountability. This will help the
country to regularly review the progress and revise strategies or political decisions based on the
challenges identified (Bekedam 2017).
2.3 Strength and barrier of country response to the issue
Strength
One of the strength of India’s response to achieving the MDGs is the focus on promoting
institutional delivery of pregnant women through the Janani Suraksha Yojana (JSY). This was a
significant step taken by India because in response to the pledge to meet MDGs, they realized
that the poor women are the ones who will significantly affect the overall MMR rate for the
country (Vimala 2015). Several research studies gave idea about the barrier to institutional
delivery among young women. Kesterton et al. (2010) showed that differences in accessibility

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and economic status had an impact on the institutional delivery rate in rural India. It is critical
that mothers deliver their babies in clinical setting so that hygienic environment can be provided
to save the mother and child from risk of any complication. However, the investigation about
factors influencing institutional delivery rates in India revealed that economic status is the
strongest predictor of choosing institutional or home delivery. Therefore, people belonging low
economic status needed side financial to increase rate of institutional delivery. Hence, JSY
targeted the right area and triggered increase in institutional delivery among pregnant women by
providing financial assistance to below poverty line households.
Barrier
Poor progress of India in achieving the MDGs for maternal health is an indication that
certain barriers restricted countrywide response to reduce MMR and improving the quality of
maternal care. Different maternal programs and initiative focused on the issues of affordability
and accessibility in improving the quality of maternal health in India. However, achieving health
equity in India is dependent on education, gender, economic status and social status. All these
factors have an impact on access to maternal and reproductive care units in the country (Alcock
et al. 2015). Education is a key factor that influences utilization of maternal service. Although
institutional delivery has increased in India, however poor progress has been seen in women
belonging to economically disadvantage segments. The limitation of programs focusing on
financial assistance for pregnant was that JSY benefits were not equally distributed. It favored
the rich people and inequalities in institutional delivery were evident (Thongkong et al. 2017).
Hence, to achieve the upcoming SDGs, there is a need to focus on addressing socio-cultural and
educational gap between the rich and poor. In preparation to achieve the SDGs for 2030, India is
focusing on learning from past mistakes and paying special attention to quality issues in maternal

9HAS 911 CONTEMPORARY HEALTH ISSUES
care apart from affordability and accessibility issues. According to World Health Organization
(2017), evidence based approach and setting specific organizational mandate is crucial to
improve the performance of skilled personal in improving quality in maternal care.
3. Conclusion
The report summarizes the progress of India in improving maternal health with support
from the improvement in key indicator of MMR from 1990 till the implementation of MDGs and
SDGs. The review of the improvement in MMR in the period between 1990 and 2015 mainly
revealed success in increasing the institutional delivery rate. However, the weakness in India’s
pledge to improve maternal health was that maternal programs and initiatives increased the rate
of institutional delivery, but ultimate goals of quality in maternal care were not achieved. This
was reason for not achieving the MDGs and a new target of SDGs was given to India. In
preparation to achieve the SDGs, India has learnt from past mistakes and focusing on skill
development of health care personnel and developing a system of continuous monitoring and
evaluation to closely identify and mitigate challenges in the process. The main recommendation
for India to successfully achieve the SDGs includes developing a framework and parameters on
the basis of which health care professionals can take the right step towards improving maternal
and newborn care. Preparing evidence-based national standards can also accelerate India
progress towards SDGs.

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4. Reference
Alcock, G., Das, S., More, N.S., Hate, K., More, S., Pantvaidya, S., Osrin, D. and Houweling,
T.A., 2015. Examining inequalities in uptake of maternal health care and choice of provider in
underserved urban areas of Mumbai, India: a mixed methods study. BMC pregnancy and
childbirth, 15(1), p.231.
Bekedam, H. 2017. SDGs: big agenda, big opportunities for India. Retrieved 25 October 2017,
from http://www.thehindu.com/sci-tech/health/sdgs-big-agenda-big-opportunities-for-india/
article8570010.ece
Fehling, M., Nelson, B.D. and Venkatapuram, S., 2013. Limitations of the Millennium
Development Goals: a literature review. Global Public Health, 8(10), pp.1109-1122.
Gaitonde, R., San Sebastian, M., Muraleedharan, V.R. and Hurtig, A.K., 2017. Community
Action for Health in India’s National Rural Health Mission: One policy, many paths. Social
Science & Medicine, 188, pp.82-90.
Hodgins, S., Evans, C., and Ricca, J. 2013. Indicators for Maternal Health: Can we move from
contact only to content and quality?. Retrieved 24 October 2017, from
http://www.mchip.net/sites/default/files/mchipfiles/Hodgins%2C%20Evans%2C
%20Ricca_arusha.pdf
Kaul, R. 2017. India’s Maternal Mortality Rate on a decline. http://www.hindustantimes.com/.
Retrieved 24 October 2017, from http://www.hindustantimes.com/health/india-s-maternal-
mortality-rate-on-a-decline/story-ZcnBG0kidtvPEkRnKNI0II.html

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Kesterton, A.J., Cleland, J., Sloggett, A. and Ronsmans, C., 2010. Institutional delivery in rural
India: the relative importance of accessibility and economic status. BMC pregnancy and
childbirth, 10(1), p.30.
Millennium Development Goals. 2017. UNDP in India. Retrieved 24 October 2017, from
http://www.in.undp.org/content/india/en/home/post-2015/mdgoverview.html
Montgomery, A.L., Ram, U., Kumar, R., Jha, P. and Million Death Study Collaborators, 2014.
Maternal mortality in India: causes and healthcare service use based on a nationally
representative survey. PloS one, 9(1), p.e83331.
Montgomery, A.L., Ram, U., Kumar, R., Jha, P. and Million Death Study Collaborators, 2014.
Maternal mortality in India: causes and healthcare service use based on a nationally
representative survey. PloS one, 9(1), https://doi.org/10.1371/journal.pone.0083331
Nair, H. and Panda, R., 2011. Quality of maternal healthcare in India: Has the National Rural
Health Mission made a difference?. Journal of global health, 1(1), p.79.
Nath, A., 2011. India's progress toward achieving the millennium development goals. Indian
journal of community medicine: official publication of Indian Association of Preventive &
Social Medicine, 36(2), p.85.
Srivastava, A., Avan, B.I., Rajbangshi, P. and Bhattacharyya, S., 2015. Determinants of
women’s satisfaction with maternal health care: a review of literature from developing
countries. BMC pregnancy and childbirth, 15(1), p.97.
Sustainable Development Goals. 2017. UNDP in India. Retrieved 24 October 2017, from
http://www.in.undp.org/content/india/en/home/post-2015/sdg-overview.html

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Thongkong, N., Van de Poel, E., Roy, S.S., Rath, S. and Houweling, T.A., 2017. How equitable
is the uptake of conditional cash transfers for maternity care in India? Evidence from the Janani
Suraksha Yojana scheme in Odisha and Jharkhand. International journal for equity in
health, 16(1), p.48.
Tripathi, N., Saini, S.K. and Prinja, S., 2014. Impact of Janani Shishu Suraksha Karyakram on
out-of-pocket expenditure among urban slum dwellers in Northern India. Indian
pediatrics, 51(6), pp.475-477.
Vimala, T., 2015. Janani Suraksha Yojana. TNNMC Journal of Community Health Nursing, 3(1),
pp.27-29.
Vora, K.S., Koblinsky, S.A. and Koblinsky, M.A., 2015. Predictors of maternal health services
utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil
Nadu. Journal of Health, Population and Nutrition, 33(1), p.9.
WHO. 2016. 5 women in India die every hour during childbirth: The Indian Express. Retrieved
24 October 2017, from http://indianexpress.com/article/lifestyle/health/5-women-in-india-die-
every-hour-during-childbirth-who-2856975/
World Health Organization 2017. Standards for improving quality of maternal and newborn
care in health facilities. Retrieved 25 October 2017, from
http://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-
quality/en/
World Health Organization. 2017. Maternal health. Retrieved 24 October 2017, from
http://www.who.int/topics/maternal_health/en/

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5. Appendices
Information brochure (Summary of findings)
Key indicators of maternal health:
 Maternal mortality rates (Annual number of female deaths per 1,00, 000 live births caused during pregnancy stage
or post delivery)
 Rate of institutional delivery
 Proportion of births attended by skilled personnels
 Complications during pregnancy
Goals for India to improve maternal health:
MDGs (2015):Reduce MMR by three quarter between 1990 to 2015 and achieve MMR of 109 per 1,00, 000 live births
SDGs (2030): Reduce global MMR to less than 70% per 1, 00, 000 live births by 2030
Progress in Maternal health status of India:
 In 1990- MMR 437 per 1,00, 000 live births
 In 2015- MMR 174 per 1,00, 000 live births
Maternal programs and initiative implemented by India to achieve MDGs:
 National Rural Health Mission (NHRM): To improve health infrastructure
 Janani-Shishu Suraksha Karyakram (JJSK)- To increase access to health care for pregnant women by providing
instutitional delivery at no cost
 Janani Surakhsa Yojana (JSY)- To provide financial assistance to women in order to increase attendance in maternal
care unit and promoting delivery in health care institutions
Strength of India’s response to maternal health:
 Recognized barriers to accessing maternity care in rural areas and people belonging to low socioeconomic group
 Emphasized on accessibility and affordability issues in maternal care
Barrier:
 Quality issues in maternal care ignored due to poor skills development in health care personnels