Gujarat ranks No 10th in India in reduction of maternal mortality ratio

By Rajiv Shah
That Gujarat has failed to govern well in improving its health indicators was once again established by the latest data on maternal mortality ratio (MMR), released by the Office of the Registrar General of India.
Latest data released by the Office of the Registrar General of India – which is responsible for collecting, collating and releasing census figures for the country as a whole – have revealed that Gujarat has once again failed to perform as well as majority of Indian states in reducing maternal mortality ratio (MMR). MMR, according to a presentation made by the Office of the Registrar General, refers to “the number of women who die as a result of complications of pregnancy or childbearing in a given year per 1,00,000 live births.” While at 122 MMR per one lakh live child births is better than all states but five – except Kerala (66), Maharashtra (87), Tamil Nadu (90), Andhra Pradesh (110) and West Bengal (117) – the rate of reduction in MMR should be a matter a major concern for those who look after the state’s health and family affairs in the Gujarat government.
Thus, the data show that not only Gujarat’s rate of fall in MMR between 2004-06 and 2010-12 was 23.75 per cent, which was lower than the all-India average, 29.92 per cent. Worse, as many as nine other states – Rajasthan, Uttar Pradesh/Uttarakhand, Maharashtra, Karnataka, Assam, Madhya Pradesh/Chhattigarh, Kerala, Bihar/Jharkhand and Andhra Pradesh registered a better performance in reducing MMR nearly over the last one decade. Almost four years ago, in 2009, a group of scholars led by Prof Dileep Mavlankar, writing in the “Journal for Health, Population and Nutrition” (2009 April; 27(2): 235–248) had found in a spot study that “progress in reducing maternal mortality has been slow and largely unmeasured or documented.”
The scholars, in their paper titled “Maternal Health in Gujarat: A Case Study” had even identified “several challenges” for reducing the maternal mortality ratio, which were not taken in fighting MMR, “including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks”. Clearly, what they said then remains true even today. They had even pointed out, “The public-health system in Gujarat faces the same set of problems relating to infrastructure, human resources, and management as the rest of the country. Despite the laudable new initiatives, such as the Chiranjeevi Yojana, training of MBBS doctors, and other innovations to fill the staff vacancies, the absence of a reliable system for the registration of maternal deaths makes it difficult to measure progress.”

Reduction in MMR between 2004-06 and 2010-12

The data show that the all-India MMR in 2004-06 was 254 deaths per one lakh live child births, which went down to 178 in 2010-12, suggesting a reduction of 29.92 per cent, which is nearly six per cent higher reduction compared to that of Gujarat. It is possible to argue – as some scholars have done in the past – that Gujarat could not reduce MMR as fast as other states because its MMR was already low, 160, in 2004-06, compared to most states, and it was not possible to bring it down that fast. This argument could have been valid in case only poorer states had shown a higher reduction in MMR. Economists like Bibek Debroy, Jagdish Bhagwati and Arvind Panagariya have long argued this out as the main reason behind a relatively low rise/ fall in Gujarat’s indicators over the years on several counts. But, as far as MMR is concerned, this does not seem to hold true.
In fact, as the data show that some progressive states which performed better continued to perform even better about a decade later. Thus, Kerala which had the lowest MMR of 81 in 2004-06, showed a fall of 30.52 per cent, to reach an MMR of 66 in 2010-12. Similarly, Andhra Pradesh, which had an MMR of 154, showed a fall of 28.57 per cent, to reach an MMR of 110. And, Maharashtra, which had an MMR of 130 in 2004-06, showed a fall of 33.07 per cent, to reach an MMR of 87. The poorer states, which began on a very high pedestal, of course, showed a faster fall in the percentage of MMR – with Rajasthan showing the best performance with a fall of 34.27 per cent, from MMR of 388 in 2004-06 to 255 in 2010-12. Same was the case with Uttar Pradesh/Uttarkhand (taken as one state), suggesting a fall of 33.63 per cent, from IMR of 440 to 292 during the period. Bihar/ Jharkhand (also taken as one state) suggested a fall of 29.80 per cent, from 312 to 219. So did Madhya Pradesh/Chhattisgarh (again taken as one state), which suggested a fall of 31.34 per cent, from 335 to 230.
Significantly, the new data have come close on the heels of a high-profile study, carried out by half-a-dozen scholars associated with the Duke University, Rand Corporation, World Bank, Stanford University and Stanford Medical School (all from US), and Sambodhi Research and Communications Pvt Ltd (New Delhi), which came to the drastic conclusion that the Chiranjeevi yojna of the Gujarat government, launched to reduce infant and maternal deaths in rural areas, has been largely unsuccessful. Published in the Bulletin of the World Health Organization (WHO), it suggests that the samples collected by the scholars have put a question mark on the project’s aim of encouraging mothers to deliver in private hospitals, with the government subsidizing the costs.
“The project”, the study says, “aimed to provide free childbirth care at participating private-sector hospitals to women who are below the poverty line. The hospitals are paid Rs 1,600 per delivery, approximately $30 to $40. The hospitals may offer additional services to patients and charge separate fees for them. By 2012, approximately 800 private-sector hospitals were participating and the program had helped pay for more than 800,000 deliveries”. Titled “Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis”, its authors, Manoj Mohanan, Sebastian Bauhoff, Gerard La Forgia, Kimberly Singer Babiarz, Kultar Singh and Grant Miller, say, there was an “increase in institutional delivery rates over time across Gujarat”, but this was “unrelated to the Chiranjeevi yojana.”
The study says, “The data collected through our study indicated that implementation of the programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points).” In fact, it underlines, “The programme was also not associated with changes in the incidence of birth-related maternal complications, the use of antenatal and postnatal services or the use of neonatal intensive care.” It underlines, “Our survey data suggests that 54% of the mothers in our sample suffered complications, including premature delivery, prolonged and obstructed labour, excessive bleeding, breech presentation, convulsions, hypertension, fever, incontinence or other birth-related problems after the programme had been implemented – and that the probability of these complications did not significantly change under the Chiranjeevi yojana.”

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