India’s maternal mortality rate is high and accounts for 20 percent of global deaths occurring due to preventable causes related to pregnancy and childbirth. Though the Maternal Mortality Ratio has dropped from 212 deaths per 100,000 live births in 2007 to 130 deaths in 2014-16, the decline is not enough to meet the Sustainable Development Goal target of 70 deaths per 1,00,000 live births, and only three states-Kerala, Maharashtra and Tamil Nadu have been able to meet the target to date.
The 2018 Health Index spearheaded by the government’s policy think-tank, the NITI Aayog, and the Ministry of Health and Family Welfare have highlighted large gaps in overall performance of health indicators between the States and Union Territories. However, having data at the sub-state/district level will help improve health indicators and the latest initiative by the Harvard University and partners based on the NFHS-4 have mapped development indicators, and procured data reveals high burden of maternal health in West Bengal, Madhya Pradesh, Uttar Pradesh and Bihar.
Anemia is a known cause of maternal deaths and risk factor for low birth weight. This is a major determinant for infant morbidity, mortality and long-term impact on health outcomes in adult life. Evidence suggests ante-natal care and institutional delivery as key health interventions to reduce maternal and child deaths.
Despite the evidence almost 53 per cent women in India continue to suffer from anemia, and the absolute gap between the highest and lowest prevalence across parliamentary constituencies is 57.5 percent. West Bengal, Jharkhand, Dadra & Nagar Haveli, Chandigarh and Rajasthan have the highest proportion of anemic women. Constituencies with the greatest proportion of anemic women who suffer from the iron deficiency disease of anemia are: Purulia in West Bengal (80 per cent), which is represented by Mriganka Mahato of the All India Trinamool Congress; Dadra & Nagar Haveli (75.9 per cent), which is represented by Natubhai Gomanbhai Patel of reigning BJP; Chandigarh (74.4 per cent), represented by BJP’s Kirron Kher; Singhbhum in Jharkhand (74.4 per cent), represented by BJP’s Laxman Giluwa; and Belurghat in West Bengal (74.4 per cent), represented by Trinamool Congress’s Arpita Ghosh.
Kerala, Nagaland, Manipur and Mizoram have the lowest prevalence of anemia. Thiruvananthapuram, which is the constituency of the India National Congress’s Shashi Tharoor, has 22.5 per cent of women suffering from anemia. However, the north-eastern state of Nagaland has the lowest prevalence of this disease amongst its female population — a mere 23.5 per cent. The constituency is represented by Tokheho Yepthomi of Nationalist Democratic Progressive Party.
Low birth weight (LBW) prevalence in India is 18 per cent, with no substantial decline in the incidence over the past few decades. The two constituencies with highest LBW are Mandsaur (35 per cent) and Ratlam (30.5 per cent) from Madhya Pradesh, the constituencies represented by BJP’s Sudhir Gupta and Kantilal Bhuria, respectively. They are followed by Karauli-Dhaulpur in Rajasthan (represented by BJP’s Manoj Rajoria) with an LBW prevalence rate of 28.3 per cent; Rampur in Uttar Pradesh with 27.5 per cent is ruled by BJP’s Nepal Singh; Sambhal in Uttar Pradesh with 27.1 per cent is represented by BJP’s Satya Pal Singh; North West Delhi area in national capital Delhi with 26.8 per cent LBW rate is represented by Udit Raj who was with the BJP but has now defected to the Congress. Ujjain in Rajasthan has 26.8 per cent of LBW, where the sitting MP is Chintamani Malviya of the BJP. The absolute gap across parliamentary constituencies is at 31 per cent, with the Northeastern state of Mizoram (4.1) with the lowest prevalence of low birth weight.
The Indian guidelines on maternal health recommend at least three antenatal (ANC) visits, but data shows poor coverage of ANC, averaged at a mere 31 per cent across the 543 constituencies of the country. The worst are across Uttar Pradesh and Bihar with eight constituencies below 10 per cent women who availed minimum of four ANC visits. Constituencies with low coverage are Bahraich in Uttar Pradesh (4.4 per cent) of BJP’s legislator Savitri Bai Phoole; Begusarai in Bihar (7.9 per cent) of BJP’s Bhola Singh; Katihar in Bihar (8.9 per cent) of Nationalist Congress Party’s Tariq Anwar; Nalanda in Bihar (9 per cent) of Janata Dal’s Kaushalendra Kumar; Darbhanga in Bihar (9.4 per cent) of BJP’s Kirti Azad; Madhepura in Bihar (9.6 per cent) of Rashtriya Janata Dal’s Pappu Yadav; and Kaisarganj in Uttar Pradesh (9.9 per cent) of BJP’s Brijbhushan Sharan Singh. The government should make efforts to increase the level of awareness and knowledge among women about the adequate utilisation of antenatal care services.
The safe motherhood intervention – Janani Suraksha Yojana (JSY) under the National Health Mission (NHM) was launched with objective of reducing maternal and infant mortality by promoting institutional delivery among pregnant women. An observational study on JSY has found it to increase institutional delivery but calls for improved implementation program. This is depictive from the average of 35 per cent women availing services across the 543 parliamentary constituencies.
There are 15 constituencies which have a very low coverage (less than 5 per cent) of women availing these health services. These are spread across Gujarat parliamentary constituencies of Ahmedabad West (1.6 per cent) of BJP’s Kirit Premjibhai Solanki, Rajkot (3.7 per cent) of BJP’s Mohanbhai Kalyanji Kundariya, Banas Kantha (4 per cent) of BJP’s Haribhai Chaudhary, Gandhinagar (4.1 per cent) of BJP’s Lal Krishna Advani, followed by Maharashtra’s Aurangabad (3.1 per cent) of Shiv Sena’s Chandrakant Khaire, Satara (3.8 per cent) of NCP’s Udayanraje Bhonsle, Jalna (4.7 per cent) of BJP’s Raosahib Patil, Parbhani and (4.9 per cent) of Shiv Sena’s Sanjay Haribhai Jadhav. Besides these, 3 BJP constituencies of Karnataka Bangalore North (4.3 per cent) of Sadanada Gowda, Bangalore South (4.3 per cent) of late Ananth Kumar and Bangalore Central (4.3 per cent) of P.C.Mohan are also under availed by the residents of these area.
The poor utilisation of services under the JSY, also reflects the low rate of institutional deliveries, with the sole exception of Gujarat attributed to the success of state run program, Chiranjeevi Yojana for improving access to institutional deliveries. Uttar Pradesh, Bihar, Jharkhand, Nagaland and West Bengal top the list of parliamentary constituencies with less than 50 per cent institutional deliveries. Of the 14 constituencies with less than 50 per cent institutional deliveries, nine of them fall under the BJP. Namely Shrawasti in UP 35.6 per cent of Daddan Mishra, Sitamarhi in Bihar 37.3 per cent of Ram Kumar Sharma, Bahraich in UP 37.9 per cent of Savitri Bai Phule, Sheohar in Bihar 43.4 per cent of Rama Devi, Singhbum in Jharkhand 44.9 per cent of Laxman Guliwa, Purvi Champaran in Bihar 45.1 per cent of Radha Mohan Singh, Dumariyaganj in UP 45.3 per cent of Jagdambika Pal, Darbhanga in Bihar 47.1 per cent of Kirti Azad, Kaisarganj in Uttar Pradesh 48.9 per cent of Brijbhushan Singh and Madhubani in Bihar 49.1 per cent of Hukumdev Narayan Singh Yadav.
The data reveals clear inequality in maternal health across parliamentary constituencies in terms of maternal mortality rate and uptake of services like ANC or institutional birth. There are overlapping constituencies with poor performance of maternal health indicators like poor utilisation of JSY, less than 10 percent women receiving IFA tablets and low rate of institutional delivery. The parliamentary constituencies includes Bahraich, Shrawasti, Kaiserganj, Sitapur in UP. Besides, Sitamarhi and Sheohar in Bihar.
Social accountability mechanism seems to be lacking among majority of parliamentary constituencies. BJP with the biggest stake which is 268 out of 543 have the worst affected constituencies in terms of maternal health indicators. The Niti Aayog 2018 Health Index calls for regular tracking of health indicators at the state level with repetitiveness of priority areas.
A step further would be to go sub-state level to districts as well as parliamentary constituencies to have a greater degree of accountability of the MP’s for implementation of programs on maternal health. And also develop monitoring mechanisms for improved maternal health outcomes. The Member of Parliament Local Area Development Scheme (MPLADS) could also be utilised for development of those areas which are on priority list and need immediate action.
The author is Senior Fellow with Observer Research Foundation’s Health Initiative.
This article was first published on ORF.