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Whither SDG goal? India's maternal mortality rate fall target 5.5% per yr, actual 4.5%

By Srinivas Goli, Parul Puri*
The maternal mortality ratio (number of maternal deaths per one lakh live births) is a key and sensitive parameter used by health policymakers to monitor maternal health conditions in particular and women's status in general in a country.
Although the maternal mortality ratio is falling at an average of 4.5% yearly, achieving the target set under Sustainable Development Goals-(SDGs)-3 has to bring down the maternal mortality ratio at the annual rate of 5.5%. Currently, India accounts for 15% of world maternal deaths, second only to Nigeria (19%).
Since the launch of Janani Suraksha Yojana under the National Rural Health Mission in 2005, there has been accelerating progress in reducing maternal deaths in India. The rise in education, age at marriage, decline in number of children per woman, and increasing use of maternal health care (pregnancy, delivery, and post-delivery care) contributed to the decline in maternal mortality ratio.
However, the progress is not uniform across the states. The latest special bulletin on maternal mortality (2015-17) from the Office of Registrar General of India suggests that nine EAG states (Assam, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, and Uttarakhand) contribute to 61% of total maternal deaths in the country.
In contrast, the five south Indian states (Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana) account for only 12% of the country’s maternal mortality. Assam has the highest (229 maternal death per one lakh live births), while Kerala has the lowest (42 maternal death per one lakh live births) maternal mortality ratio in the country.
Sample Registration System of Office of Registrar General of India provides data for only major states with no evidence on the district-level picture of maternal deaths. Along with other smaller states, the estimates for all districts shoulder immense importance for policy, planning, and monitoring progress towards maternal mortality-related sustainable development goals.
Districts are critical administrative units for micro-level policy exclusion and monitoring. Therefore, identification of “hot-spots” of the issue at hand acts as an effective way of pursuing the problem.
To fill this critical gap in the knowledge, researchers from the University of Western Australia, Australia, International Institute for Population Sciences, India, and the University of Portsmouth from the United Kingdom have together put out a Pre-Print which, for the first time in India, provide maternal mortality ratio for all states and districts of India**.
Authors analyzed a total of 61,982,623 live births and 61,169 maternal deaths reported during 2017-20 at the Government of India’s Health Management Information System (HMIS) portal and validated it using data from the Office of Registrar General of India.
Their findings suggest that 24 states and 450 districts have a maternal mortality ratio above 70 deaths per one lakh live births. Among the states, Arunachal Pradesh reported the highest maternal mortality ratio, while Maharashtra reported the lowest. Authors identify five states with maternal mortality ratios greater than or equal to 210.
Eight states and three union territories registered maternal mortality ratio in the range of 140-209, while eleven states shows 70-139 maternal deaths per 1 lakh live births. A startling finding is about the presence of Punjab in the range of medium to high maternal mortality ratio. A comparison of successive rounds of information from the Office of Registrar General of India reveals a surprising rise in maternal mortality ratio in Punjab. 
We are guessing that it could be due to unsafe sex-selective abortions leading to the death of women in the state. However, a detailed examination of reasons for such a rise is needed from the state government’s side.
Maternal Mortality ratio by States, 2017-2020
Among the districts, the highest maternal mortality ratio is found in the Tirap district in Arunachal Pradesh and the lowest in Kinnaur and Lahul & Spiti in Himachal Pradesh. Overall, 115 districts registered a maternal mortality ratio greater than or equal to 210; 125 districts shows a range of 140-209; while 210 districts fall in the range of 70-139, and only 190 districts reported maternal mortality ratio less than 70.
Among the districts with maternal mortality ratio ≥210, 46 districts belonged to the Central Region, and 35 districts were located in the North-eastern region, while 17 districts belonged to the Northern region, 16 from the Eastern region and one from southern India. The findings illustrated enormous within-state variations.
Maternal Mortality ratio by Districts, 2017-2020
Authors also put out that in order of their importance reduction in higher-order births and poverty, improving health infrastructure, years of schooling, maternal health care, maternal age, and nutrition can significantly improve progress towards achieving the maternal mortality target set under SDGs.

Road ahead

The study findings can immensely useful for identifying ‘hot spots’ of maternal mortality within the states, thus aiding in micro-level maternal health care policy and planning. These “hotspots” (cluster of districts) need to initiate immediate action to meet the ambitious SDG-3 target for maternal mortality ratio and thereby eliminate all preventable maternal mortality.
Although achieving SDG target for all the districts of India is a difficult task, especially for most high maternal mortality ratio (>210) districts, the states that made a concerted effort to reduce maternal mortality, especially post-2005 provide guidelines on best practices and paths for how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths.
In particular, post-2005 maternal mortality ratio reduction in Maharashtra, Telangana and Andhra Pradesh are very impressive. Further, these researchers advance that despite some caveats about the completeness of information in a few states, HMIS is a reliable, cost-effective, and routine source for monitoring progress in reducing avoidable maternal mortality in India and its states and districts.
Therefore, the government of India must bring in a mission mode stratagem to strengthen the vital registration system at a national level with an inspiration of reasonably good quality registration evident in case of maternal deaths under HMIS.
---
*Respectively: Australia India Institute (AII) NGN Research Fellow, UWA Public Policy Institute, University of Western Australia, Perth, and Assistant Professor at the Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi; Doctoral Fellow at the Department of Mathematical Demography and Statistics, International Institute for Population Sciences, Mumbai
**The data and analysis that inform this piece are available in our preprint paper titled, “Estimates and Correlates of District-Level Maternal mortality ratio in India” on medRxiv

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