MDGs – Goal 5: disparities in maternal health in India

MDGs – Goal 5: disparities in maternal health in India

The Millennium Development Goals (MDGs) are Global Agenda aim to cut extreme poverty by half, ensure every child has the chance to go to school and live a long and healthy life, and bring discrimination against women to an end. While the goal 3 reaffirms commitment to gender equality in education, employment and political participation, the goal 5 Improve Maternal Health exclusively deal with women health. The targets and indicators linked to the fifth goal are: Improve Maternal Health by reducing maternal mortality three-quarters, between 1990 and 2015. The indicators are the maternal mortality ratio and proportion of births attended by skilled health personnel.

This brief perspective focuses on maternal health and disparities in the progress in India. This analysis of MDG5 and disparities, have national relevance to achieve MDG5, because, there are established evidence show that regional and social disparity in health status in India. Therefore, it’s important to address the disparity issue to achieve the goal.

Maternal health includes the provision of ante-natal care (ANC), delivery care, and post-natal care (PNC). In India, ante-natal care is provided in the public sector through the network of primary health centres and urban health posts primarily by female health workers who are expected to visit women in their homes and provide the basic services. In India the National Family Health Survey periodically (every five year) collects information on antenatal, delivery, and post-natal care and so on.

Antenatal Check-up

The coverage of antenatal care in India is heading towards a high level. The NFHS-2 estimates that during the late 1990s ante-natal check-up was conducted by qualified professionals in case of 65 per cent of births . Kerala is the forerunner in this with near universal coverage closely followed by Tamil Nadu which is also nearing the full coverage level. Andhra Pradesh too has translated its effort into good results (93 per cent coverage) followed by Maharashtra and Bengal (90 per cent each). Other states with high coverage by antenatal check-up are Himachal Pradesh, Karnataka, Gujarat, and Jammu and Kashmir. Orissa has shown good achievement in this indicator. However, at the other end Uttar Pradesh and Bihar are two states with a very poor coverage (34 and 36 per cent respectively).

The pattern has not changed much over the period though generally the level has improved between the two NFHS surveys. Kerala remained at the apex and Tamil Nadu had also rank-wise the same position; Rajasthan and Bihar fare poorly. Uttar Pradesh has slipped to a very low level. On the other hand, the level has risen substantially in Orissa.

Overall, the coverage is lower for the SC and the ST populations compared to the Others; the deprivation is especially greater for the ST women. This is not unexpected since the ST population living in relative isolation and often in hilly areas has poor access to health services. On the other hand, though the SCs do not get as much care as the Others, the gap is relatively narrow. The SCs, though generally discriminated against, live in villages along with others and are more successful than the STs in obtaining services.

The relative deprivation of the SCs and the STs is seen in almost all the states Assam is a notable exception, but this is not due to a good coverage for the scheduled groups in the state, rather on account of poor coverage for all the communities. Since Kerala has reached a near universal coverage, obviously hardly any difference among social groups is seen. In many other states, the gap between the SCs and Others is narrow. However, a few states exhibit large disparity between SCs and Others, Rajasthan, Karnataka, Haryana, and Uttar Pradesh in the two surveys and Bihar, West Bengal and Punjab in at least one round of the NFHS.

In almost all the states that have substantial ST populations, the social gap is quite wide between Others and STs compared to Others and SC. Both the surveys depict this. In some states, the condition of the STs is extremely poor compared to the Others. Andhra Pradesh, Madhya Pradesh, Maharashtra, and Uttar Pradesh are notable in this aspect and in a few other states also the condition of the STs is quite dismal.

TT Injection and IF Supplements

Two tetanus toxoid (TT) injections are recommended to be given during a pregnancy. Tamil Nadu leads in TT injection along with Kerala. In all states, 60 per cent or more women are immunized for tetanus as estimated by the NFHS-2. The lowest slabs are the BIMARU states. The pattern closely matches with that of antenatal check-up; however, overall the coverage of TT injections is higher than that of antenatal check-ups by about 10 points. Injections are given on a large scale on fixed days and campaigns improve awareness and accessibility. On the other hand, check-ups are more individually catered and hence presumably have lower coverage. The social disparities in TT coverage are more or less similar to those observed for antenatal check-ups. Wide gap between SCs and Others is seen in a few states, Karnataka, Rajasthan, Uttar Pradesh and Himachal Pradesh in NFHS-1 and Bihar in NFHS-2. By the late 1990s, the practice of taking TT injections was fairly widespread among the SCs as well resulting in only small social gaps. However, the STs do not seem to get the tetanus protection as much as the SCs. Wide gaps are seen in almost all the states. Injection campaigns do not seem to reach the tribal populations that suffer from locational disadvantage.

Delivery Care

In India, a majority of deliveries, especially in rural areas, continue to take place at home. Only a small proportion of deliveries take place in health institutions such as hospitals, maternity homes, public or private, primary health centres, and sub-centres. The NFHS- 3 revels that the percentage of deliveries in health institutions is 41 at latest year 2005-06. There was some progress during the period 1992-93 and 1998-99 as 26 and 34 percent respectively. There are, however, large inter-state variations in the practice to seek institutional delivery care. As estimated by the NFHS-3, only 22 percent in Uttar Pradesh and Bihar and 30 percent in Madhya Pradesh and 32 in Rajasthan received institutional delivery. Kerala and Tamil Nadu do exceptionally well and are at the top as in the case institutional delivery care.

At the national level, SC women get much less institutional care compared to Others, by about 10 percentage points, and the ST women even less so, by 20 percentage points . In delivery care from the public sector, the gaps are narrower; in fact, the percentage of deliveries taking place in government institutions is almost the same for SC and Other women and it is only marginally lower for ST women according to NFHS-2. Obviously, women from the non-scheduled groups, being financially better off, utilise the private sector substantially more than the scheduled women. The social gap, between SC and Other women in securing institutional delivery is wide in most states. Exceptions are Kerala and Maharashtra where the gap is narrow. In some states like Assam, Himachal Pradesh and Bihar, the gap is narrow but these have low level of coverage for all the communities. In the case of deliveries at public institutions, the social gaps present a totally different picture. First, the SC: Others gap is generally narrower for care in government institutions than in overall care. Only Orissa and Jammu and Kashmir show wide gaps in NFHS-2. In a few states, SCs actually get greater coverage from the public sector than the Others; notably in Kerala and to some extent in Gujarat, as well as in Maharashtra and West Bengal in NFHS-2. This does not, however, imply that the government sector seeks to cater more to the SCs but rather that the Others, having greater financial resources, prefer the private sector for delivery care.

Overall, the STs get much less institutional care than the SCs and the Others. This is true in most of the states with substantial ST populations, the sole exception being Assam. In the matter of deliveries in public institutions, the gaps persist but are narrower. Thus, the STs get poorer delivery care than the SCs and the Others in both public institutions as well as overall. In this manner, a clear contrast is seen between the SCs and the STs. While the SCs are not able to obtain private delivery care as much as the Others, affordability being the main obstacle, the STs do not get either public or private sector service as much as the Others.

Medical Assistance at Birth/Delivery

Lack of professional assistance at delivery is a major cause of maternal and neo-natal mortality. Traditionally, village midwives and women at home have been assisting at delivery. Over time, many women have begun to seek the help of doctors or at least trained midwives at the time of delivery. According to the NFHS-3, in India, 48 percent of deliveries have received medical assistant by health personnel and remaining half of new born babies were born without any medical assistance. The34 percent and according to the NFHS-2, 42 percent of deliveries were assisted by a professional, that is, a doctor or a trained midwife. In some states, Kerala, and Tamil Nadu, the percentage is quite high, close to or over 90 percent. Andhra Pradesh, Punjab and Maharashtra are also progressing towards high levels. But the poorest conditions are seen in Assam, Bihar, Madhya Pradesh, Orissa, and Rajasthan, with only 20-30 percent coverage.

As seen in many other indicators, the SCs fare poorly compared to the Others, and the STs are even worse-off. The pattern is similar in many states but there is departure from the general pattern in a few states. Kerala shows narrow gaps because professional care is available to nearly all sections including the SCs, and Assam and Bihar show narrow gaps because the coverage is low among all the social groups; high level equity in Kerala contrasted to low level equity in the latter two states. Medical assistance is good in Tamil Nadu, though there is a visible gap between two communities (Others and SCs). The ST: Others gaps are quite wide in almost all the states except Assam. In a few states, Andhra Pradesh, Gujarat, Orissa, and Maharashtra, these are extremely high. The poor coverage for the ST women could be on account of poor access to health professionals but also possibly the continuing trust on traditional midwives.

The importance of maternal health care has been well recognised in India for long. The recent reproductive and child health programme has placed greater emphasis on this aspect of health. Yet, the recent surveys reveal that the goal of providing professional health care during pregnancy and delivery is far from being achieved. While a few states, notably Kerala and Tamil Nadu, are nearing complete coverage in many aspects of maternal care, the situation is quite poor in states like Uttar Pradesh, Bihar, and Rajasthan; Orissa seems to have improved recently and risen over the latter states. Since maternal health care is provided free of cost by the primary health care network involving Community Health Centres, Primary Health Centres, and Sub-centres, all sections should get this care. Yet the coverage is lower for the scheduled groups, and the deprivation is worse for the ST women than the SC women; probably a result of the locational disadvantages the STs face. But that this is not the only factor contributing to deprivation can be seen from the fact that in many states, even SCs women, do not get the same care as the Others.

S. Venkatesan
Reference: National Family Health Survey -I and II.