604 Factfile

Factfile

Current Situation of Maternal Health in India

Fertility Rate and Pregnancy Age

Marriage and Fertility Rates
Marriage and fertility	NFHS-3 (2005-06)	Urban	Rural
Women age 20-24 married by age 18 (%)	44.5	28.1	52.5
Total fertility rate (children per woman)	2.68	2.07	2.98
Median age at first birth for women age 25-49	19.8	20.9	19.3
Source: National Family Health Survey-3 (2005-06), India fact sheet, p. 3.

Maternal Mortality

Maternal mortality ratio (MMR). Source: (MoHFW, 2003c). Each year in India, roughly 30 million women experience pregnancy and 27 million have a live birth. The Maternal Mortality Ratio in India is 407 per 100,000 live births (SRS, RGI 1998).

MMR. Source: http://www.unicef.org/infobycountry/india_statistics.html

Maternal mortality ratio, 2000-2007 reported – 300

Maternal mortality ratio, 2005, adjusted 450.

Quantum of maternal death. Source: http://southasia.oneworld.net/todaysheadlines/maternal-and-neonatal-death-still-very-high-in-india citing Unicef’s State of the World’s Children Report 2009.

78,000 women die from pregnancy and delivery related complications in India each year.

58% of adult women are anemic. Anemia increases maternal death.

In the vast majority of maternal deaths – more than 99 per cent, according to the 2005 UN inter-agency estimates – occurred in developing countries. Half of these (265,000) took place in sub-Saharan Africa and another third (187,000) in South Asia. Between them, these two regions accounted for 85 per cent of the world’s pregnancy-related deaths in 2005. India alone had 22 per cent of the global total.

Causes of maternal mortality in rural India	%
Anemia	24
Hemorrhage	23
Abortion	12
Toxemia	10
Puerperal sepsis	10
Malposition	7
Others	14
Source: Registrar General India, Survey of Causes of Death (Rural), 1998.

Link Between Child (under 5) Mortality and Maternal Health
Disease and Nutritional Status (per 1000)	Children alive	Children dead	Difference	Pearson Chi-square test#
Suffer from TB	5.06	7.75	-2.69	chi2(1)=6.48**
Suffer from	11.47	15.81	-4.34	chi2(1)=6.2029**
Asthma
Suffer from	3.37	7.26	-3.89	chi2(1)=15.42**
Diabetes
Suffer from	5.20	5.98	-0.78	chi2(1)=0.1776
Thyroid
Suffer from any diseases	23.55	35.58	-12.03	chi2(1)=17.60***
Underweight	422.41	438.31	-15.90	chi2(1)=8.26***
Normal	539.26	529.22	10.04	chi2(1)=2.85*
Overweight	38.33	32.47	5.86	chi2(1)=6.498**
No Anemia	377.27	353.03	24.24	chi2(1)=63.73***
Severe Anemia	17.94	31.90	-13.96	chi2(1)=63.73***
Moderate Anemia	183.21	231.92	-48.71	chi2(1)=63.73***
Mild Anemia	421.58	383.15	38.43	chi2(1)=63.73***
Note: # Here, the null hypothesis of independence of discrete health and child mortality attributes are tested. Figures in parenthesis are the degrees of freedom. *p<0.01, p<0.05, p<0.10. Source*: Manoj K. Pandey, Maternal Health and Child Mortality in Rural India, ASARC working paper 12, 2009.

The table below indicates that 50 per cent of maternal deaths occurred before the age of 25 years of which 15 per cent had parity one and about 43 percent with parity three or more. About 48 per cent deliveries were conducted at home by untrained dais. About 69 per cent of maternal deaths occur during postnatal period. About 59 per cent of the women died in hospital and 16 per cent died on the way. This may be due to the late referral of women to hospital by untrained dais. As presented in the table below, the main causes of deaths were observed as post partum hemorrhage (17%), septicemia and anemia (13%). It has also been observed that 7.5 per cent of the maternal deaths reported to be due to retained placenta and about 8.6 per cent due to non-obstetric reasons.

Profile of Maternal Deaths
Caste	UP	Uttaranchal	Delhi	Maharashtra	Karnataka	Total	Per cent
SC	14	7		2	2	25	26.60
ST	0	1		8	2	11	11.70
OBC	20		2		1	23	24.47
Others	23	5	3		4	35	37.23
Total	57	13	5	10	9	94	100.00

When Did Death Occur
	UP	Uttaranchal	Delhi	Maharashtra	Karnataka	Total	Per cent
Ante Natal	17	4	1	0		22	23.40
During	4	1	0	2		7	7.45
Childbirth
Post Natal	36	8	4	8	9	65	69.15
Total	57	13	5	10	9	94	100.00

Place of Death
	UP	Uttaranchal	Delhi	Maharashtra	Karnataka	Total	Per cent

Home	10	6		5	2	23	24.73
Institution	36	7	3	3	6	55	59.14
On the way
to hospital	11		2	2		15	16.13
Total	57	13	5	10	8	93	100.00

Place of Delivery
	UP	Uttaranchal	Delhi	Maharashtra	Karnataka	Total	Per cent
Home	29	7		7	1	44	46.81
Institution	12	2	4	3	7	28	29.79
Not
delivered	16	4	1		1	22	23.40
Total	57	13	5	10	9	94	100.00

Delivery Conducted by Whom
	UP	Uttaranchal	Delhi	Maharashtra	Karnataka	Total	Per cent
Trained	4	1		1		6	8.33
Dai
Untrained	21	4		6	1	32	44.44
Dai
ANM/
LHV	1	1				2	2.78
Nurse	3				1	5	6.94
Doctor	10	2	4	1	6	23	31.94
Others	2	1		1		4	5.56
Total	41	9	4	10	8	72	100.00
Source: ICMR pilot study, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India, 2003.

Utilization of Reproductive Health Services

Use of Family Planning Methods
Family planning	NFHS-3	Urban	Rural
Any method (%)	56.3	64.0	53.0
Any modern method (%)	48.5	55.8	45.3
Female sterilization (%)	37.3	37.8	37.1
Male sterilization (%)	1.0	1.1	1.0
IUD (%)	1.8	3.4	1.1
Pill (%)	3.1	3.9	2.8
Condom (%)	5.3	10.0	3.3
Total unmet need (%)	13.2	10.0	14.6
Source: NFHS-3 India fact sheet, p. 3.

Use of Family Planning Methods, Comparing UP and Maharashtra
Family Planning	Uttar Pradesh (Total)	Uttar Pradesh (Urban)	Uttar Pradesh (Rural)	Maha- rashtra (Total)	Maha- rashtra (Urban)	Maha-rashtra (Rural)
Any method (%)	43.6	56.3	39.7	66.9	66.7	67.1
Any modern method (%)	29.3	42.3	25.2	64.9	64.0	65.8
Female sterilization (%)	17.3	18.7	16.8	51.1	44.2	57.8
Male sterilization (%)	0.2	0.5	0.1	2.1	1.1	3.2
IUD (%)	1.4	3.2	0.8	3.1	5.5	0.8
Pill (%)	1.7	3.2	1.3	2.5	3.8	1.3
Condom (%)	8.7	16.6	6.2	6.4	10.0	3.0
Total unmet need (%)	21.9	15.5	23.8	9.6	9.9	9.3
Source: NFHS-3, UP and MH fact sheets.

Maternal Nutrition

Nutritional Status of Adult Women (age 15-49)
Nutritional Status	NFHS-3 (2005-06)	Urban	Rural	NFHS-2 (1998-99)	NFHS-1 (1992-93)
Women whose Body Mass Index is below normal (%)	33.0	19.8	38.8	36.2	NA
Source: NFHS-3, India fact sheet. One in three women 15-49 years of age has a Body Mass Index (BMI) below 18.5 indicating severe nutritional deficiency and under-nutrition.

Interstate Variations in Maternal Nutrition UP and Maharashtra
Nutritional Status	Uttar Pradesh			Maharashtra
	(Total)	(Urban)	(Rural)	(Total)	(Urban)	(Rural)
Women whose	34.1	23.3	37.2	32.6	20.7	43.0
Body Mass Index is below normal (%) (BMI<18.5kg/M2) Source: NFHS-3, MH and UP fact sheets.

Maternity Care
Maternity care (for births in the last 3 years)	NFHS-3 (2005-06)	Urban	Rural	NFHS-2 (1998-93)	NFHS-1 (1992-93)

Mothers who had at least 3 antenatal care visits for their last birth (%)	50.7	73.8	42.8	44.2	43.9

Mothers who consumed IFA for 90 days or more when they were pregnant with their last child (%)	22.3	34.5	18.1	Na	Na
Births assisted by a doctor/nurse/LHV/ANM/other health personnel (%)	48.3	75.2	39.1	42.4	33.0
Institutional births (%)	40.7	69.4	31.1	33.6	26.1

Mothers who received postnatal care from a doctor/nurse/LHV/ ANM/other health personnel within 2 days of delivery for their last birth (%)	36.4	60.7	28.1	NA	NA
Source: NFHS-3 India fact sheet, p. 3.

Illiteracy and Use of Maternal Care Services in Different Parts of India
State	Illiteracy % female	Illiteracy % male	TT (%)	IRFL (%)	HDEL (%)	ANC (%)
Haryana	54.1	27.9	70.2	60.1	16.7	72.7
Himachal Pradesh	43.3	21.1	71.0	71.9	16.1	76.0
Jammu & Kashmir	49.0	26.4	78.0	70.8	21.7	79.6
Punjab	47.9	34.2	86.7	73.9	24.8	87.9
Rajasthan	74.7	39.5	34.7	29.3	11.6	32.8
Madhya Pradesh	66.0	36.4	51.3	44.2	16.0	53.4
Uttar Pradesh	68.0	36.2	44.3	29.6	11.0	45.5
Bihar	71.6	39.9	37.0	21.4	12.1	37.5
Orissa	58.6	31.1	63.0	49.9	14.2	62.9
West Bengal	44.8	24.6	77.7	56.3	31.5	75.4
Arunachal Pradesh	57.7	38.0	43.1	44.5	19.8	48.9
Assam	49.2	30.3	43.9	39.5	11.1	43.9
Manipur	36.9	14.8	61.6	35.6	22.6	63.4
Meghalaya	39.9	33.1	44.6	49.6	29.7	51.8
Mizoram	11.1	6.4	85.9	63.7	48.7	88.9
Nagaland	28.0	19.9	43.3	23.8	6.1	39.3
Tripura	36.4	19.0	65.2	53.0	30.2	64.9
Goa	27.1	11.7	92.8	89.3	87.1	95.9
Gujarat	49.6	24.7	69.9	69.3	35.7	76.2
Maharashtra	44.6	20.6	81.6	70.6	44.1	82.8
Andhra Pradesh	62.0	39.6	81.2	76.1	33.0	87.8
Karnataka	53.7	32.1	76.5	74.8	37.6	84.2
Kerala	17.6	10.1	94.1	91.0	88.4	98.1
Tamil Nadu	54.1	23.2	93.6	84.0	63.6	94.5
ANC- Livebirths among mothers receiving antenatal care; HDEL- Livebirths among mothers delivering in hospitals; IREL- Livebirths among mothers receiving iron and folic acid tablets during pregnancy; TT- Livebirths among mothers receiving at least one dose of tetanus toxoid vaccine.

Current Situation of Neonatal and Infant Health in India

1. Infant and neonatal mortality rates

Situating India’s IMR and NMR in a global context. Source: Save the Children Report (2004).

Trends in perinatal and infant mortality show a slow but steady decline in infant mortality rates (IMR), less for neonatal mortality (NMR) and almost no change for rate of stillbirths. Each year 27 million infants are born in India. Around 10% of them do not survive to 5 years of age. In absolute figures, India contributes to 25% of the over 10 million under-five deaths occurring worldwide every year. Nearly half of the under-five deaths occur in neonatal period.

Infant mortality declined from 79 deaths per 1,000 live births in NFHS-1 (1992-93) to 68 in NFHS-2 (1998-99) to 57 in NFHS-3 (2005-06).

Birth spacing and infant mortality. Source: NFHS-3, Final Report. The infant mortality rate is 86 for births less than two years apart, 50 for births 24-35 months apart, and 30 for births 36-47 months apart. Twenty-eight per cent of births in recent years have been spaced less than two years apart despite the lower chance of survival for these births.

2. Nutrition status of infants

Situating the status of underweight children in India in a global context. Source: UNICEF, State of the World’s Children Report (2009).

Of the 148 million underweight children in the developing world, India accounts for 2/3rds.

Nutritional Status of Children Under Three in India

Low birth weight and breastfeeding. Source: A. Gupta, Y.P. Gupta. Status of Infant and Young Child Feeding in (49 districts) of India: A National Report of the Quantitative Study. Breastfeeding Promotion Network of India, Delhi, 2003.

The proportion of low birth weight babies remains high at one third of all births. This is linked to breastfeeding which is critical to reducing neonatal mortality and child survival . It is estimated that in India 28% of mothers initiate breastfeeding within one hour of delivery and only 39.7% practice exclusive breastfeeding till 6 months.

Age-wise distribution of prevalence of underweight reveals that malnutrition peaks during the first two years of life. From 11.9% prevalence among 0-6 month old infants, it reaches 58.5% in 12-23 month old children. This steep rise in malnutrition in the first two years is also caused by poor infant feeding practices.

Malnutrition and infant mortality. Source: Planning Commission (2007). Report of the working group on integrating nutrition with health, 11th five year plan.

Malnutrition has been responsible, directly or indirectly (maternal nutrition) for 60% of the 10.9 million deaths annually among children under five.

Link between nutritional status of children under three and maternal nutrition status. Source: NFHS-3, Final Report (2005-2006), Chapter 10, ‘Nutrition and Anaemia’.

Trends in Nutritional Status of Children

Percentage of children under age three years born to ever-married women classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by residence, India, NFHS-3 and NFHS-2.

Measure of nutrition	NFHS-3 (2005-06)			NFHS-2 (1998-99)
	Urban	Rural	Total	Urban	Rural	Total
Height-for-age
%age below 3 SD	16.4	23.8	22.0	19.7	30.2	27.7
%age below 2 SD1	37.4	47.2	44.9	41.1	54.0	51.0
Weight-for-height
%age below 3 SD	6.8	8.3	7.9	5.3	7.1	6.7
%age below 2 SD1	19.0	24.1	22.9	16.3	20.7	19.7
Weight-for-age
%age below 3 SD	10.6	17.4	15.8	11.3	19.6	17.6
%age below 2 SD1	30.1	43.7	40.4	34.1	45.2	42.7
No. of children	6,436	20,105	26,541	5,741	18,475	24,215
Note: Table is based on chidren who stayed in the household the night before the interview. Each of the indices is expressed in standard devation units (SD) from the median of the 2006 WHO International Reference Population. Table is based on children with valid dates of birth (month and year) and valid measurements of both height and weight. 1. Includes children who are below 3 standard deviation (SD) from the International Reference Population median.

3. Health status of newborns and infants in India

Childhood illnesses. Source: NFHS-3 Final Report.

In the 2 weeks before the survey, 6% of children under the age of 5 had symptoms of an acute respiratory infection. 15% of children were reported to have fever in the two weeks preceding the survey. 9% of children had diarrhea.

Treatment of Status of Childhood Illnesses
Treatment of childhood diseases (children under 3 years)	NFHS-3	Urban	Rural
Children with diarrhea in the last 2 weeks who received ORS (%)	26.2	32.7	24.0
Children with diarrhea in the last 2 weeks taken to a health facility (%)	58.0	65.3	55.6
Children with acute respiratory infection or fever in the last 2 weeks taken to a health facility (%)	64.2	78.1	59.9
Source: NFHS-3, India fact sheet.

4. Immunization

Vaccination coverage. Source: NFHS-3, India Factsheet. Less than half of children 12-23 months are fully vaccinated against the 6 major childhood illnesses: tuberculosis, diphtheria, pertussis, tetanus, polio and measles. However most children are at least partially vaccinated and only 5% have received no vaccinations at all.

Inter-state variations. Source: NFHS-3, Final Report. Progress in vaccination coverage varies widely among the states. Less than one-third of children are fully vaccinated in Nagaland, Uttar Pradesh, Rajasthan, Arunachal Pradesh, and Assam. At the other end of the spectrum, at least three-quarters of children have received all the recommended vaccinations in Tamil Nadu, Goa, and Kerala. Between NFHS-2 and NFHS-3, full vaccination coverage increased substantially in a number of states, including Bihar, Chhattisgarh, Jharkhand, Sikkim, and West Bengal. However, coverage actually worsened in other states, such as Andhra Pradesh, Gujarat, Maharashtra, Punjab, and Tamil Nadu.