Fostering a commitment to stop maternal deaths, Pg6

Context

• Despite significant progress, India’s Maternal Mortality Ratio (MMR) remains at 93 deaths per 1,00,000 live births (2019–21). This editorial by explores persistent gaps, reasons for preventable maternal deaths, and targeted strategies to eliminate them.

Key Highlights:

1. India’s MMR has improved from 103 (2017–19) to 93 (2019–21).

2. Wide disparity across States:

• Kerala: Lowest MMR at 20
• Madhya Pradesh: Highest at 175
• Other States (e.g., Assam, UP, Bihar): High MMRs (100–175)
• Southern States: Better performing, though with intra-regional variations

3. MMR data derived from Sample Registration System (SRS) estimates.

Detailed Insights

1. Three Delays Model (Deborah Maine, 1992):

• First Delay: In recognising danger and deciding to seek care.
• Second Delay: In accessing transportation to reach medical facility.
• Third Delay: In initiating timely care at the health facility due to systemic lapses.

2. Systemic Gaps in FRUs (First Referral Units):

• 66% vacancy in specialists across 5,491 CHCs.
• Inadequate blood banks or emergency response facilities.

3. Common Medical Causes of Maternal Deaths:

• Post-partum haemorrhage (bleeding after delivery) – the biggest killer.
• Obstructed labour due to malnourishment and pelvic contraction.
• Hypertensive disorders of pregnancy – often unmonitored or untreated.
• Unsafe abortions by untrained practitioners.
• Sepsis due to infections and delayed hospital admissions.

4. Preventive and Curative Measures Needed:

• Emergency blood transfusions and timely Caesarean sections.
• Early antenatal registration and routine checkups.
• Availability of skilled obstetricians, anaesthetists, paediatricians.
• Ensuring institutional delivery over home births.

5. Role of Schemes and ASHA Workers:

• Janani Suraksha Yojana, financial incentives, and ASHA support have improved institutional delivery rates.
• 108 Ambulance services and NHM's Emergency Transport Systems improved access.

6. Kerala Model Highlights:

• Confidential maternal death review system helps identify systemic gaps.
• Use of uterine artery clamps, suction canulas, and advanced interventions even for rare complications.
• Includes mental health attention for antenatal depression and post-partum psychosis.

Way Forward

• Operationalise at least four FRUs per district, ensuring 24/7 availability.
• Strengthen maternal death reviews, not just reporting but action-oriented auditing.
• Fill specialist vacancies with incentives and compulsory rural service.
• Expand mental health integration in maternity care.
• Regular capacity-building of ASHA, ANMs, and primary-level nurses.

Scientific/Strategic Concepts Involved

• Three Delays Framework – globally adopted model for analyzing maternal deaths.
• Maternal Mortality Ratio (MMR) – maternal deaths per 100,000 live births.
• FRUs – designated referral units with required infrastructure and personnel.
• Atonic Uterus, amniotic fluid embolism, and diffused intravascular coagulation – life-threatening complications requiring specialized care.
• Uterine artery clamps and suction canulas – modern life-saving tools for obstetric care.