Over many years, India has made considerable progress on many of the maternal & child mortality indicators. However, we are still far away from achieving the targets under the UN SDGs. Data indicates that while some states are already achieved the targets, few other states continue to bring down India’s progress.
The National Health Mission (NHM) was launched by the central government in 2013 subsuming the National Rural Health Mission and the National Urban Health Mission. The objective of the mission is to strengthen the healthcare systems in the country. Under the scheme, the central government provides technical and financial support to the States/UTs for the same on the basis of proposals submitted by them. Under the National Health Mission, targets have been set in alignment with the targets of the National Health Policy 2017 (NHP) and Sustainable Development Goals (SDG-3).
Investing in the health of women and children is a vital part of the right to health. One of the core areas the NHM focuses on is Reproductive and Child Health. For this, the Government of India is implementing a Reproductive, Maternal, Newborn Child plus Adolescent Health (RMNCH+A) strategy to improve ‘Maternal and Child health’ outcomes such as morbidity and mortality.
In this story, we look at the progress States have made with respect to four key mortality indicators of reproductive and maternal health, viz. Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR), Under 5 Mortality Rate (U5MR), and Neo-natal Mortality Rate (NMR). Data for this story has been compiled from the Sample Registration System survey.
MMR has dropped from 556 in the 1990s to 113 in 2016-18 period
Maternal Mortality Ratio is defined as the proportion of maternal deaths per one lakh live births. As maternal deaths are considered a rare event, the estimates have been calculated by pooling in the data for three years.
In 1990, India’s MMR was as high as 556 meaning 556 women died during childbirth for every lakh live births. Approximately, 1.38 lakh women died every year due to complications related to pregnancy and childbirth back then. India has made significant progress in reducing MMR in recent years. MMR has dropped from 130 in 2014-16, to 122 in 2015-17, and 113 in 2016-18. As per targets set under SDG-3, the United Nations aims to bring down the global MMR to less than 70 deaths per lakh live births by 2030. As per NHP 2017, the target for MMR is 100 per lakh live births by 2020. This clearly indicates that India has not achieved the target and still has quite some distance to cover to achieve both the targets under NHP as well as SDG.
MMR in Assam is 215, three times the target set by UN for 2030
MMR across states varies from a high of 215 in Assam to a low of 43 in Kerala. State-wise data indicates that only the southern states of Andhra Pradesh, Telangana, Kerala, and Tamil Nadu, and Maharashtra have already achieved the target under SDG-3 of less than 70 deaths per lakh live births in 2016-18. Tamil Nadu, Kerala, and Maharashtra have had an MMR below 70 since 2014-16.
On the other side, the MMR in Assam was as high as 237 in 2014-16 and has dropped to 215 in 2016-18. However, it is still almost twice the national MMR. Meanwhile, in Uttar Pradesh, the MMR increased from 201 in 2014-16 to 216 in 2015-17 and has dropped below 200 for the first time in 2016-18. Uttarakhand which had an MMR of 201 and Jharkhand 165 in 2014-16, have reported MMR below 100 in 2016-18. While most states have brought down the MMR during this period, Punjab has reported an increase from 122 to 129.
India’s IMR has declined over the years
Infant Mortality Rate is defined as infant deaths (less than one year) per thousand live births. India’s IMR has decreased considerably from 129 per 1000 live births in 1971 to 110 in 1981 and from 80 in 1991 to 32 in 2018.
Kerala’s IMR is 7 while MP has reported 48
Madhya Pradesh has the highest IMR of 48 deaths per thousand live births in 2018. The state’s IMR was 47 in 2016 and 2017. Other states which have witnessed an increase in the IMR during the three years are Chhattisgarh (38 in 2017 to 41 in 2018) and Jharkhand (29 in 2016 to 30 in 2018). Meanwhile, Kerala is the only state which has a single-digit IMR (7), the lowest in the country. Delhi’s IMR has dropped from 18 to 13 in the 3 years between 2016 & 2018. Maharashtra’s IMR has remained stagnant at 19 in all these three years.
The government’s target under NHM is to reduce IMR from 37 deaths to 26 deaths per 1000 live births. It is observed that only 9 states- Karnataka, Jammu & Kashmir, West Bengal, Punjab, Himachal Pradesh, Maharashtra, Tamil Nadu, Delhi, and Kerala have achieved the target in 2018.
11 states have achieved NHP’s 2020 NMR target
Neonatal Mortality Rate (NMR) refers to the death of a live-born baby within the first 28 days of life. NMR is calculated as the number of infants that have died per thousand live births. The United Nation’s SDG-3 target is to reduce neonatal mortality to at least as low as 12 deaths per 1000 live births by 2030. That is, NMR should be below 12 by 2030. The NHP’s target is to bring NMR down to 20 by 2020.
India’s NMR dropped from 24 in 2016 to 23 in 2018 and ranges from 14 in urban areas to 27 in rural areas. This is almost twice the NMR target the UN SDGs set for 2030. In 2018, 11 states had already achieved the NMR target set by the NHP of 2017. These are Gujarat, Telangana, Jammu & Kashmir, Karnataka, West Bengal, Himachal Pradesh, Maharashtra, Punjab, Delhi, Tamil Nadu, and Kerala. Kerala has reported the lowest NMR of 5 while the NMR of Madhya Pradesh was the highest at 35, in 2018.
NMR has increased in MP, UP, and Chhattisgarh
Unlike the trend in most states, Madhya Pradesh has reported an increase in NMR in the 3 years between 2016 & 2018. Similarly, Uttar Pradesh and Chhattisgarh, which have the second and fourth highest NMR in India have also reported an increase during this period. Punjab and Maharashtra have maintained NMR at 13 between 2016 and 2018. Uttarakhand has shown the most significant improvement in NMR in the three years- from 30 to 22 deaths per 1000 live births.
India’s U5MR has also declined but varies across states
U5MR is the probability per 1,000 births that a new-born baby will die before reaching age five, if subject to current age-specific mortality rates. In simpler terms, U5MR is defined as the number of deaths of children under 5 years of age in a given year per 1,000 live births in that year.
India’s U5MR was 39 in 2016, which dropped to 37 in 2017, and stands at 36 in 2018. Despite the decline, India’s U5MR continues to be significantly higher than the UN’s SDG 3 target to keep it at least as low as 25 deaths per 1000 live births by 2030. The NHP’s 2020 target for U5MR is 32.
Only 7 states have managed to attain the SDG target in 2018 itself. These are Himachal Pradesh, Jammu & Kashmir, Punjab, Maharashtra, Tamil Nadu, Delhi, and Kerala. Like in the case of other mortality indicators, Kerala has also reported the least U5MR of 10. Madhya Pradesh has reported an increase of U5MR to 56 in 2018 and continues to record the highest U5MR in the country. Jharkhand and Maharashtra have also reported a marginal increase in the U5MR in the last three years. A total of 11 states have achieved the NHP’s 2020 U5MR target of 32 per 1000 live births.
India has made progress, but still far from achieving targets under SDG
The four mortality indicators discussed above are indirect indicators about the availability and access to health facilities. They also provide an understanding of other social indicators such as education, nutrition, and immunization. Most of these deaths referred to under these indicators are preventable provided there is necessary intervention at the right time.
On the whole, what is evident from the above data is that India has made considerable progress in all these indicators. However, we are still far from achieving the UN’s SDG targets. Even the NHP’s targets which are more realizable have not been achieved by India and the majority of the states. Across indicators, it is seen that certain states like Kerala, Delhi, and Tamil Nadu are performing much better than the states like UP, MP, and Jharkhand. These trends call for a more targeted approach in states where the indicators are still quite high. The progress made by many states may be short-lived since the pandemic has curtailed the provision of many health facilities and affected routine health services. The government must ensure the availability of these facilities alongside the vaccination drive for COVID-19.