Achieving Millennium Development Goals 4 and 5 in India

Review article

DOI: 10.1111/j.1471-0528.2011.03112.x www.bjog.org

Achieving Millennium Development Goals 4 and 5 in India A Chatterjee,a VP Pailyb a FRCOG, Salt Lake City, Kolkata, Indiab FRCOG, Vakkanal, Thrissur-5, Kerala, India Correspondence: Prof A Chatterjee, FRCOG, BA 49, 1st Avenue, Sector -1, Salt Lake City, Kolkata 700 064, India. Email [email protected]

Accepted 21 July 2011.

This review relates to achieving the Millennium Development Goals (MDGs), especially MDGs 4 and 5, by India by the year 2015. India contributes the maximum number of maternal deaths (68 000) to the global estimate of 358 000 maternal deaths annually. Infant mortality rate (IMR) is also high at 50 per 1000 (2009). Low budgetary spending on health, poverty, lower literacy, poor nutritional status, rural–urban divide and lack of trained workers in the health sector are cited as reasons for a high maternal

mortality ratio and IMR. Increased spending by the Government of India on the health sector has started to show encouraging results. Recent assessments by world bodies like the World Health Organisation have given hope that MDGs 4 and 5 are achievable. Keywords MDG4, MDG5, MMR India, IMR India, Under 5

mortality India.

Please cite this paper as: Chatterjee A, Paily VP. Achieving Millennium Development Goals 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–59.

Background India is a fast developing country, with an area of 3.2 million km2 or about one-third of the area of the USA. It is the biggest democracy in the world along with extremes of diversity in all spheres of life. Its population of 1.21 billion is second only to that of China.1 The population was only 350 million in 1947, when India gained independence.

Maternal and child health statistics The total number of maternal deaths of 68 000 per year is the highest of any country.2 The total fertility rate was 2.7 in 2005–063 and the percentage of women of reproductive age was 48.9.3 The adolescent birth rate was 45.9 per 1000 women in 2005–06.3 The maternal mortality ratio (MMR) was estimated as 230 in 2008.2 On the child health front, the data are again alarming. The perinatal mortality rate was 48.5 per 1000 live births in 2005–06.3 The latest available figures indicate that the infant mortality rate (IMR) is 50 per 1000 live births and the under-5 mortality rate is 66 per 1000 in 2009.4 The latest census report released on 31 March 2011 shows a fall in the decadal growth rate by 4% (from 21.54% to 17.64%) and a rise in the total literacy rate by 9% (from 65% to 74%) with literacy of males at 82% and of females at 65%.1

Specific (numbered) Millennium Development Goal (MDG) 4 and 5 targets for India Reduction in maternal mortality Hard data on the actual MMR for India are not available. The results given here are based on sample surveys or estimates (Table 1). The MMR for India in 1992 was estimated to be 437 per 100 000 live births with a gradual reduction to an estimated 230 per 100 000 live births in 2008.2 The target for 2015 is 109 per 100 000, but at current levels of decline the MMR is expected to reach 135 per 100 000 by 2015.5 The place of birth (at home or in an institution) and the type of assistance available (untrained or trained) have improved over the years. In 1992–93 only 25.5% of births were attended by skilled health personnel whereas in 2009 this was 79%6 and expected to reach 90% by 2015. In India, attendance by skilled health personnel is not synonymous with institutional deliveries as it includes deliveries conducted at home by trained health workers (see Table 1).

Access to reproductive health The data relating to the period 1990–2010 given in Table 2 show an improvement in all these areas, albeit rather slow. In 2009 about 90% of women had at least one antenatal visit.6 The unmet need for family planning was only 12.8% in 2005–06.3

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG

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Table 1. MDG 5A: reduction in maternal mortality 1990

1995

2000

2005

2010

2015

Maternal mortality ratio

437 (1992)

407 (1998)

301 (2001)

254 (2006)

230 (2008)

Proportion of births attended by skilled health personnel

25.5% (1992–93)

No data

39.8% (2002–03)

48.8%

79% (Inst. del. 76% + 3% SBA home del.) (CES 2009)6

Target 109 (expected to achieve 135)5 Expected to achieve around 90%

SBA, skilled birth attendant. Source: National Family Health Survey, Coverage Evaluation Survey (CES).

Table 2. MDG 5B: achievements in access to reproductive health

Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage (at least one visit and at least three visits) Unmet need or family planning

1990

1995

2000

43.5 (1991) 76.02 (1991) 64.6% 43.9% (1991–92)

No data 54.02 (1997) No data

46.9 (2000) 51.24 (2000) 66% 44.2% (1998–99) 15.8% (1998–99)

19.5% (1992–93)

2005

2010

2015

56.3 (2006–07) 45.9 (2005) 76% 52% (2005–06)

No data No data 89.6% 68.7% (2009)

No data No data No data

12.8% (2005–06)

No data

No data

Source: National Family Health Survey, Coverage Evaluation Survey.

orders, scheduled tribe women, women with no education and women in households with a low wealth index.3 These differentials suggest that improving the coverage of antenatal programmes requires special efforts to reach older and higher-parity women and women who are socio-economically deprived. There is region-wide disparity in antenatal care. While states like Kerala, Tamil Nadu, Karnataka and Goa have near universal utilisation of antenatal care, a state like Bihar has only 34% utilisation. Overall, in India 75% of pregnant women received at least one antenatal visit, while 51% received three antenatal visits during 2007–08. This went up to 89.6% and 68.7% respectively in 2009.6 As seen in Table 4, there is a gradual but definite improvement of antenatal care services over the years.

An indirect indicator of child health is the proportion of 1-year-old children immunised against measles. These are given in Table 3. The targets of 38 per 1000 for the under5 mortality rate and 26.7 per 1000 for IMR are difficult to achieve.

Continuum of care Antenatal care In India ‘complete antenatal care’ is considered to include three antenatal care visits, two tetanus toxoid injections and 90 doses of iron and folic acid (IFA) tablets.7 Women who do not receive complete antenatal care are usually older women, women having children of higher birth

Table 3. MDG 4: reduction in child mortality between 1990 and 2015

Under-5 mortality rate Infant mortality rate Proportion of 1-year-old children immunised against measles

1990

1995

2000

2005

2010

2015

112 (1990) 80 (1990) 32.7% (1990)



85 SRS (2004) 57 (NFHS-3, 2005–06) 59% (NFHS-3, 2005–06)

66 SRS (2009)28 50 (CES 2009) 74.1% (CES 2009)

Target 38 Target 26.7 No data

SRS, Sample Registration System. Source: National Family Health Survey 3 (NFHS-3), Coverage Evaluation Survey 2009 commissioned by UNICEF.

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Achieving MDGs 4 and 5 in India

Table 4. Antenatal care indicators for India NFHS-1 (1991–92)28

Mothers who had at least one antenatal visit (%) Mothers who had at least three antenatal visits Mothers who take iron and folic acid for 90 days or more (%) Mothers who received tetanus toxoid vaccine (minimum of two doses) (%) Mothers who received complete antenatal care

NFHS-2 (1998–99)29

NFHS-3 (2005–06)3 Rural

Urban

All India

CES 20096

64.6 43.9 No data

66 44.2 No data

72 43.7 18.8

91 74.7 34.8

76 52 23.1

89.6 68.7 31

53.8

66.8

72.6

86.4

76.3

86.9

10.2

23.7

15

26.5

No data

No data

NFHS, National Family Health Survey; CES, Coverage Evaluation Survey.

Intrapartum care Since independence in 1947, there has been a paradigm shift in the Government of India’s approach to provision of intrapartum care. Initially rural health services were established with primary health centres (PHCs) and subcentres. The PHCs had a trained nurse midwife but the subcentres were staffed by locally recruited women trained only for a short period. The latter were later recruited as regular staff called the auxiliary nurse midwife (ANM). However, intrapartum care was provided mostly by untrained traditional birth attendants (TBAs). From 1992 to 1996 these TBAs were trained under the scheme called Child Survival and Safe Motherhood7 supported by the World Bank and United Nations Children’s Fund (UNICEF). However, later it was realised that trained TBAs did not improve the intrapartum care and in 2005 the emphasis was put on promoting institutional delivery by a skilled birth attendant (SBA). Table 5 shows the increase in births attended by skilled health personnel. These include deliveries in institutions and those at home attended by trained health workers. A trained health worker can be a doctor, nurse, midwife, ANM or a trained TBA. The coverage evaluation survey of 20096 has reported 76% were institutional deliveries and 3% home deliveries by an SBA.

Under the National Rural Health Mission (NRHM) launched in 2005, there was an increase in cash incentives for institutional deliveries. Many state governments (e.g. Tamil Nadu) added further incentives to promote institutional deliveries and such states achieved a drastic increase in institutional deliveries.8 The percentage of births assisted by a doctor/nurse/lady health visitor (LHV)/ANM/other health personnel trained in emergency/essential obstetric care (EOC) went up gradually from 35.1% in 1991–92 to 42.4% in 1998–99, 48.8% in 2005–06 and 79% in 2009.

Postnatal care Those women who delivered in institutions or who received care from a doctor/nurse/LHV or ANM within 2 days of delivering at home are considered to have received postnatal care. Data for the period 2005–06, collected during the National Family Health Survey (NFHS-3),3 are given in Table 6. There was wide variation between urban and rural settings. There is no structured pattern for postnatal care in the country as a whole even now. This is an area that needs urgent attention. A new trend evolving, after the increase in hospital deliveries under the Janani Suraksha Yojana

Table 5. Status of delivery and postnatal care in India NFHS-1 (1991–92)28

Proportion of birth attended by skilled health personnel (%) Institutional deliveries (%) Mothers who received postnatal care from a doctor/nurse/LHV/ANM/other health personnel within 2 days of delivery for their last birth (%)

NFHS-2 (998–99)

29

NFHS-3 (2005–06)3 Rural

Urban

All India

CES 20096

35.1

42.4

37.4

73.4

48.8

79

26.1 No data

33.6 No data

28.9 28.6

67.4 61

40.7 36.8

76 NA


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Table 6. Indicators of family planning services Indicators Total unmet need for family planning (%) Unmet need for spacing Unmet need for limiting Contraceptive prevalence rate (current use of contraceptive methods)

Table 7. Present scenario of child health in India 3

NFHS-3 (2005–06)

13.2% of women of reproductive age (15–49) who are married or in consensual union 6.3% 6.8% 56% of currently married women aged 15–49

(JSY) scheme of the NRHM, is that mothers get discharged very soon after delivery after receiving their cash incentives for delivering in a health facility. This deprives them of the postnatal care for mothers and essential newborn care.

Family planning Contraceptive use in India is around 56% among currently married women aged 15–49. The fertility rate also has declined to 2.7 in 2005–06 with many states having already achieved the replacement fertility level of 2.1. Female sterilisation accounts for two-thirds of contraceptive use. But still the unmet need for family planning is estimated to be 13.2%. This is in addition to an unmet need for ‘spacing’ of 6.3% and unmet need for ‘limiting’ of 6.8%. All these figures refer to married women (Table 6).

Newborn care In 2008, 1 million neonates died in India.9 This constituted about 55% of the under-5 mortality. The main causes were prematurity (13%), birth asphyxia (10%) and various infections (19%). Neonatal deaths are directly influenced by the midwifery care received at birth for causes such as birth asphyxia and prematurity. Breastfeeding practices also influence the number of neonatal deaths. The estimated neonatal mortality rate for India in 2008 was 35 per 1000 live births.10 The target laid out in the National Plan of Action for Children 2005 was 18 per 1000 live births by 2010.11 This target was not achieved.

MDG target

Health indicator

1990

2005–06

T 4:113 Under-5 mortality rate 112 85** T 4:114 Infant mortality rate 80 6012 T 4:115 Proportion immunised 32.7% 59%** for measles

Recent 66 SRS 200924 53 SRS 200924 74.1% CES 20096

SRS, Sample Registration System; CES, Coverage Evaluation Survey. **NFHS-3 (2005–06)3.

Causes of maternal, newborn and child mortality and morbidity Medical causes of maternal death The leading medical causes of maternal death are haemorrhage 37%, sepsis 11%, complications of abortion 8%, hypertensive disorders 5% and obstructed labour 5%.12 But the proportion of these causes varies between states and regions. For example, the leading causes of maternal death in the state of Kerala, where confidential review of maternal deaths is being done, are haemorrhage 19.8%, hypertensive disorders 13.2%, amniotic fluid embolism 9.7%, venous thromboembolism 5.8% and heart disease 9.4%.13 Under the heading of haemorrhage, postpartum haemorrhage is the leading cause.

Non-medical factors contributing to maternal deaths While searching for the non-medical factors contributing to maternal death it is prudent to consider the vastness and the diversity of India. India is about one-third the size of the USA and with respect to area many of its states are the same size or larger than many sovereign countries of western Europe. Also, for several years since achieving independence in 1947, international political situations have forced India to divert much of her hard earned money to defence purposes, rather than towards the health of her own people. Factors contributing to poor maternal health are as follows.

Care for the children aged under five An estimated 1.8 million children aged under 5 years died in 2008. This includes 1 million neonatal deaths. The under-5 mortality rate has shown a steady decline from 112 in 1990 to 85 in 2005–063 and 66 in 2009.6 Over the same periods the infant mortality was 80 in 1990, 57 in 2005–06 and 50 in 20096 (Table 7). The MDG 4 target for under-5 mortality is 38 per 1000 live births by 2015. India is very unlikely to achieve the target at the present rate of decline in under-5 mortality.

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Political will Health is primarily a state issue as per the Indian constitution. This potentially causes conflict between the centre and the states, where two different or opposing political parties may be in power. Health economics Of the total health expenditure of 6.1% of gross domestic product in 2002, the government’s share was only 1.3%


Achieving MDGs 4 and 5 in India

whereas private expenditure was 4.8%32. This means that only 20.3% of expenditure on health comes from the government; 77.4% is from the patient’s pocket. In the USA public health expenditure is around 50% and in western European countries it is over 80%.14 Contrary to popular belief, the contribution from international funding agencies like WHO and UNICEF on health was a meagre 2.3%.15 To make matters worse, there is very little insurance coverage available for maternity services in India. The higher cost of a hospital delivery makes a home delivery the preferred option for the poor. About 18% of women and husbands of those who delivered at home consider cost of delivery at health facilities too high to afford.6 Realising this the Government of India has come forward to provide cash incentives for hospital deliveries since 2005 through the JSY scheme under the NRHM.16

Infrastructural problems Private and government (public) hospitals coexist in most places, but the poor depend on the health centres run by the government because they provide a free service. But these centres have drawbacks including a perpetual shortage of funds, equipment and skilled staff. There are not enough government centres, which also leads to poor service provision. The doctor:people ratio in India is 1:1722 (www.financial express.com/news/doctorpopulation-ratio-stands-at-11-722/ 139534/. Accessed 12 July 2011)35, compared with the doctor:people ratio of the UK which is 1:416.17 There are about 1 million vacancies for nurses in India. Doctors from India (56 000) account for the largest share of migrant health workforce in Organisation for Economic Co-operation and Development countries.18 Organisational failures This is one of the main causes of several delays in accessing maternity care in India: • Because of low economic power coupled with illiteracy, there is always delay in seeking help during maternal and neonatal emergencies. • Lack of timely availability of transport—car or ambulance—leads to a delay in reaching the health centres in time. Ready cash to pay for transport is not usually available and this worsens the situation, even when transport is available. • Even when the patient reaches the desired health centre, overcrowding, lack of equipment and other medical supports coupled with a chronically understaffed environment delays emergency management. Issues of management in the health system are also important. India has only three technical officers for maternal health at the national level, and there are no maternal health directors in most states. Lack of manage-

ment capacity in the health system has led to poor quality services and slow progress.19

Socio-economic determinants • Low literacy rate: The literacy level of women in the reproductive age group (15–49 years) in India is just 55%. In all, 41% of women and 18% of men have never been to school.3 Illiteracy in mothers doubles the IMR. The rate of antenatal care and institutional delivery is higher in women who are educated. The literacy level of women in various states influences performance in maternal health. Thirty-seven percent of illiterate pregnant women did not receive any antenatal care whereas the corresponding figure for women with more than 12 years of education was only 1.7%. Educated women are more likely to take a full course of IFA, receive tetanus toxoid and have an institutional delivery. • Poverty: Twenty-seven percent of the Indian population live below the poverty line. Poor pregnant women are less likely to receive proper nutrition and maternal care. For pregnant women in the lowest quintile of wealth index, 41.3% did not receive any antenatal care and only 13% had institutional delivery.3 • Poor social status of women: Any decision making regarding health care during pregnancy is usually taken by the husband or his family and not the pregnant woman. Forty-one percent of women did not get any antenatal care because their husband/his family did not think that it was important or did not allow women to access antenatal care.3 • Reduced awareness of health care needs: There is reduced awareness about the need for antenatal care and need for delivery in a health facility. Seventy-two percent of women who did not deliver at a health facility did not feel it was necessary to deliver at a health facility.3 • Age of marriage: Early marriage is an age-old tradition in India. Sixteen percent of girls between 15 and 19 years are already pregnant. The IMR is 77 in teenage mothers, while it is 55 in the post-teenage group.3 Pregnancy in teenage girls is twice as common in rural as in urban areas in India. • Health and nutritional status of women: Poor nutritional status of women leads to increased maternal mortality. The percentage of women with anaemia is 55.6%.3 Moreover only 23% of pregnant women take IFA for 90 days and 58% of pregnant women are found to be anaemic. Ignoring evidence The concept of EOC, essential to save mothers with complications of pregnancy or childbirth, was not universally implemented in India until recently. It has been recognised that EOC is one of the most cost-effective strategies for


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reducing maternal deaths anywhere in the world Averting Maternal Death and Disability (AMDD Network Conference, Kuala Lumpur).20 However, this was not implemented in India due to lack of focus and limited management capacity. Even today the Government of India does not systematically monitor how many EOC facilities are fully functional. Most of the first referral units have no staff to offer EOC on time. The NFHS-3 (2005–06) has shown an institutional delivery rate of only 39%.3 Since then there has been an increase in institutional deliveries due to JSY; however, a substantial percentage of births are still domiciliary and India needs to provide the option of SBA at the community level. Recently, under NRHM there has been a greater focus on strengthening EOC services. For many years, India lacked a focus on developing a skilled professional midwifery cadre, which has led to persistent dependence on TBAs for deliveries leading to high maternal deaths. In the past, the Indian government has spent a lot of money and time on TBA training, despite the knowledge that TBAs cannot reduce MMR. The limited resource allocations have even been diverted from maternal health. A lack of qualified midwives in India is a major human resource constraint for providing locally accessible, skilled delivery care for rural women. This has led to a questionable quality of health care, particularly maternal health care. Among women receiving antenatal care for their most recent birth, 28% had no abdominal examination, only 64% had their blood pressure checked, and 63% had their weight measured.3 MBBS doctors often refuse to work at the village level, mostly due to lack of social and medical infrastructure at rural facilities.

Causes of under-5 mortality The major causes of under-5 mortality, other than neonatal mortality, are pneumonia 11%, diarrhoea 11% and other infections (see Table 8).

Malnutrition About 30% of live births are of low birthweight (