Dr. Sylvia Karpagam
A special bulletin on Maternal Mortality Ratio (MMR) released by the Census Commissioner, Ministry of Home Affairs, showed that Karnataka had declined from 92 per lakh live births in 2016-18 to 83 in 2017-19. While the quickest response of the government is self-appreciation and self-promotion, there is a need to look at the MMR in much more depth and with more seriousness. Basically one needs to engage with the data and also analyse it rather than just celebrating ups and downs.
All quantitative data needs to have some qualitative backing as well as checks and balances in terms of understanding how reliable (consistent) or accurate (capturing what it was meant to capture) the data is. Some points to keep in mind when interpreting MMR.
Most deliveries in Karnataka are taking place in private hospitals which are known to under-report, so strengthening and making it mandatory for private hospitals to report mortality as well as cause of death would be a crucial step to ensure data is accurate and reliable. Along with that, a detailed analysis of non-maternity related deaths in women especially in the reproductive age group is required. This would require investment by the government into training as well as human resources to independently scrutinize all causes of deaths of women in the reproductive age. There are many groups that get left out of the data tracking system. Those who access abortion services illegally or seen as having illegitimate abortions are often not recorded as maternal deaths. Similarly, surrogacy sometimes doesn’t garner the same legitimacy as a maternal death as a ‘normal’ pregnancy.
It is also important to keep in mind that many deliveries go on to Caesarian sections. In Karnataka, as per the NFHS Caesarean sections in private hospitals have gone up from 40.3% in NFHS4 to 52.5% in NFHS-5. It would be important to look at long term complications as well as morbidity related to pregnancy and child birth along with mortality. For every woman who dies, another twenty suffer from injuries, infections or disability. The quality of life of women following pregnancy has not received the attention it deserves.
While government and other health officials may be quick to rejoice over the drop in MMR, it is crucial to understand that retrospective analysis of data is one thing, but the more important aspect is to proactively identify crucial interventions that can prevent maternal deaths and introduce them. For instance, following the Covid pandemic and associated lockdown, many, especially public, health facilities have not recovered fully and one could make an informed guess that MMR would have gone up over the last 2.5 years. For this trend to be halted, efforts have to be made to strengthen public facilities including the large tertiary maternity hospitals which had been arbitrarily converted to secondary covid facilities. Over the last two years, this anticipatory extra effort has not been visible in the planning by the government. Ante-natal, delivery and post-natal services were badly affected. Communalisation of the pandemic, which began early, had serious implications for pregnant Muslim women in Karnataka. Break up of MMR based on caste, religion and geographic location will throw up crucial gaps in essential health service delivery. The government needs to publicly place how it is going to address gaps in service delivery which essentially means that some women have better chances of survival that others. This should be considered as discrimination by the health system and the government in power which then need to be held accountable.
In no way should crucial indicators of health and access to healthcare be linked to punitive measures. ASHA workers who report maternal deaths may face harassment and abuse for making the primary health centre or taluk/district hospital ‘look bad’. Suppressing/fudging data is more common than is often acknowledged. The common premise that those who show ‘good indicators’ are rewarded and those who show ‘poor indicators’ are penalized should be condemned. If an area or a community shows high MMR, there should be concerted systemic effort to address this rather than taking one or the other service provider to task.
Currently the government is proposing increasing the age of marriage of women from 18 to 21 years. Along with the numerous other adverse outcomes of this, in the context of MMR, henceforth pregnancy in any woman before the age of 21 years will be classified as illegal and can therefore go underground with its inevitable consequence of under-reporting.
Hemorrhage due to nutritional anemia is the leading (preventable) cause of maternal deaths. In Karnataka, anemia in non-pregnant women age 15-49 years has gone up from 44.8% in NFHS-4 to 47.8% in NFHS -5. Anemia in pregnant women has gone up from 45.4% to 45.7%. This is expected to rise in Karnataka following the nutritionally/economically disastrous cattle slaughter ban as well as the lockdown related loss of livelihood, income and social security schemes. The government seems to not make a connect between this and an expected rise in MMR.
A sensitive indicator of maternal health services is the availability and distribution of skilled birth attendants, nurses, pharmacists, lab technicians, specialists etc. We also need to map the availability/accessibility of emergency drugs, blood banks, ambulance services etc. Publicly run urban maternity homes in Bengaluru played a very positive role and it shows that having good quality maternity care close to where people live can be life-saving. Women cannot be expected to shell out thousands of rupees accessing healthcare.
The lifetime risk of maternal deaths and complications in a woman can be around 1 in 5400 in high income countries and almost 1 in 45 in low income countries, with the more number of pregnancies a woman goes through increasing her risk. This statistic doesn’t translate to women and communities being responsible for their own maternal health outcomes. It is documented that when women are more educated, they are likely to have better nutritional and pregnancy related outcomes, healthier babies and overall lesser mortality/morbidity in themselves and their children. They are likely to have fewer babies irrespective of their caste or religion location. While data shows that education is key, the recent hijab controversy in Karnataka shows that the government is not invested in education of girls/women. This is indeed a great cause for concern.
Data can be misleading and also inaccurate. While Karnataka may celebrate the drop in MMR, this may not be a real cause for celebration.