In 1990, India recorded a devastating maternal mortality rate of 556 deaths per 100,000 live births – above the global average and according to World Bank figures, for years almost exactly in line with the average for lower and middle-income countries.

But the rapidly-developing economy, now the fifth largest in the world valued at around $3 trillion, opted to make faster and more equitable improvements in maternal health a priority in line with the Millenium Development Goals.

In 2005, the government launched the National Rural Health Mission with the objective of rebalancing the lopsided rural/urban divide of healthcare across the expansive South Asian nation, which is a third of the size of Europe.

“Around independence maternal mortality rates were terrible, and through the 1950s and 1970s, the focus was on parent planning and sterilisation and not so much on women,” said Genevie Fernandes, a research fellow at the Global Health Governance Programme at the University of Edinburgh. “Women were dying for something absolutely preventable. If they had to get blood, for example, some would need to travel 20 km to reach a local blood bank, but it would be too far and too late.”

"If you improve and increase hospital-based care, it is effective in reducing mortality"

According to Fernandes, the introduction of India’s National Health Surveys, which began in 1994 and have since had four more iterations, was an important precursor.  “This was the first time maternal mortality was properly inspected,” she added. “But the real game-changer was the National Rural Health Mission.”

Under the National Rural Health Mission, and complementary schemes such as Janani Suraksha Yojana and Janani Shishu Suraksha Yojana, Indian women have been offered not only free but cash-incentivised deliveries in public and private hospitals and are entitled to free transport to the hospitals with the accompaniment of a health worker. The creation of Accredited Social Health Activists (ASHA) in 2005 helped ease this societal shift, with these community workers, who now number around 800,000, linking villages to the public health system.

As a result, since 2005, the proportion of institutional deliveries in public facilities has almost tripled, from 18% in 2005 to 52% in 2016, according to the World Health Organization. When factoring in births in private facilities, the figure is at 79%.

At the same time, the country’s maternal mortality rate has tumbled to 122 per 100,000 live births – remarkably just over a fifth of the number recorded a generation ago.

“It was a paradigm shift in health programmes,” said Sandhya Gautam, a programme manager for the New Delhi-based NGO, Centre for Health and Social Justice, who has been working on maternal health and rights since 1994. “The Rural Health Mission was an aggressive approach to increase institutional births and to reduce home births and in doing so it got to the heart of addressing these health imbalances.”

Overall, 75% of rural births are now supervised, compared with 89% of urban deliveries, albeit with stark regional differences remaining between the poor, remote northeastern states such as Assam and wealthier southern regions like Kerala, where social determinants have also played a role in reducing maternal mortality.

“The evidence states if you improve and increase hospital-based care, it is effective in reducing mortality,” said Dr Aparna Hegde, a qualified urogynaecologist and founder of NGO Armman, which works across 16 states in India.

“But more and more women are becoming literate, the age women are getting married is not as low as before and education has helped reduce levels of anaemia, which can lead to a higher risk of death during childbirth.”

Hegde, who has been advising the government on improving antenatal care, says that she expects India’s fifth National Health Survey to show an even greater reduction in maternal mortality and a greater balance for rural areas. But with levels mortality and morbidity levels still far above those in the US, there is a lot further to go.

"We need to expand access, improve the quality of health services and address social determinants"

“The focus has to shift to ensuring there is a complete package,” she added. “High-risk pregnancies must be identified early, we don’t want them to end up in the hospitals too late. Likewise, postnatal care has been relatively neglected.”

That could be in the process of changing. Between 2018 and 2025, India has pledged to increase health spending from 1% of GDP to 2.5%, an estimated rise of around $100 billion, with reducing maternal mortality considered a significant factor.

As it becomes a global superpower, however, there are hopes that the equity of India’s healthcare will be further improved.

“While the government has succeeded in improving access, we need to expand access, improve the quality of health services and address social determinants through multi-sectoral action via other programmes like education and sanitation,” said Professor Fernandes. – Peter Yeung

(Photo credit: Kelly Sikkema/Unsplash)