[Answered] Despite declining national MMR, some states struggle with high maternal deaths. Examine the socio-economic and systemic factors hindering progress and suggest community-centric approaches for equitable maternal healthcare outcomes.

Introduction

India’s Maternal Mortality Ratio (MMR) has shown sustained decline, reaching 93 per 1,00,000 live births (2019–21). Yet, stark disparities among states highlight persistent socio-economic and systemic roadblocks to maternal health equity.

India’s Uneven Progress on MMR

1. India’s MMR declined from 103 (2017–19) to 93 (2019–21) according to the Sample Registration System (SRS).
2. States like Kerala (MMR: 20) and Tamil Nadu (49) lead in maternal health outcomes, while Madhya Pradesh (175) and Assam (167), both EAG states, continue to struggle.
3. These gaps reflect unequal access to quality healthcare, compounded by socio-economic vulnerabilities.

Socio-Economic Factors Hindering Progress

1. Poverty and Malnutrition: Poor women, especially in EAG states, often suffer from low BMI, anaemia, and undernutrition, increasing complications during childbirth. NFHS-5 reports over 50% of women in Bihar and Uttar Pradesh are anaemic.
2. Education and Awareness: Low female literacy and patriarchal decision-making delay recognition of obstetric emergencies. Cultural norms around home births, often overseen by untrained birth attendants, heighten risk.
3. Teenage Pregnancy and Early Marriage: NFHS-5 indicates that over 20% of women in West Bengal and Bihar are married before 18, leading to stunted mothers with underdeveloped pelvises, increasing obstructed labour risks.
4. Geographical Isolation: Remote tribal, hilly or island communities face transportation delays, often reaching health facilities too late.

Systemic Factors Contributing to Maternal Deaths

1. Three Delays Framework (Deborah Maine, 1992): Delay in decision-making at home due to low awareness, delay in reaching care, especially in remote areas and delay at health facility, due to staff shortages and lack of emergency care.
2. Inadequate Health Infrastructure: Over 66% vacancy in specialist posts at CHCs (RHS, 2022), lack of functioning First Referral Units (FRUs) with blood banks and surgical facilities and shortages in obstetricians, anaesthetists, and functional OTs.
3. Poor Emergency Preparedness: Unavailable ambulance services, delayed access to blood transfusions, and untrained staff contribute to deaths from Postpartum Haemorrhage (PPH), the leading cause of maternal mortality.
4. Weak Monitoring and Accountability: Inadequate implementation of maternal death surveillance and response (MDSR) and confidential reviews.

Community-Centric and Policy Recommendations

1. Strengthen Grassroots Health Networks: Expand role of ASHA workers and SHGs in promoting antenatal check-ups, institutional deliveries, and postpartum care. Offer mobile health units and telemedicine in remote areas.
2. Operationalise FRUs Effectively: Prioritise filling of vacancies in CHCs and FRUs. Ensure 24/7 emergency obstetric care, blood banks, and critical equipment.
3. Kerala Model of Maternal Death Review: Adopt Kerala’s confidential review method to understand local causes and prevent recurrence.
4. Emergency Transport and Referral System: Strengthen 108 ambulance service with real-time coordination and community response systems.
5. Adolescent Health Programs: Promote delayed marriage and pregnancy through school-based awareness and menstrual hygiene initiatives.
6. Address Underlying Health Conditions: Integrate maternal care with TB, malaria, and anaemia control programs in high-risk areas.
7. Digital Health Monitoring: Implement Mother-Child Tracking Systems (MCTS) to ensure continuity of care, supported by real-time dashboards at district level.

Conclusion

Reducing maternal mortality equitably across states requires tackling entrenched socio-economic inequities, systemic bottlenecks, and embracing community-led health strategies for universal, respectful, and timely maternal healthcare access.