Introduction 

When the nation moves towards higher standards of development there are several parameters that it needs to take care, not forgetting one of the crucial ones being the health of its citizens. India stands today striving towards the road ahead of the 2030 Sustainable Development Goals (SDGs). UNICEF (2018) declared that “Maternal Mortality Ratio of India has declined by 8 points from 130 / 100,000 live births in 2014-16 to 122/ 100,000 live births in 2015-17 (6.2 per cent decline) This translates to 2000 additional mothers saved annually in 2017 as compared to 2015. Total annual deaths declined from 32,000 maternal deaths in 2015 to 30,000 deaths in 2017. This translated to every 20 minutes a mother dying due to pregnancy or childbirth related cause” (UNICEF, 2018). India has been struggling and fighting this battle for decades now since its acceptance of the Millennium Development Goals (MDGs). It failed to achieve MDG 5 at the end of 2015, whereby its maternal mortality rate (MMR) stood at 140 per 100,000 live births. The Millennium Declaration was adopted in 2000 by United Nations General Assembly committing towards essential goals for human development such as peace, security, gender equality, eradication of poverty and overall sustainable development measures for human mankind. 

‘Maternal Mortality’ that is defined as maternal or obstetrical death, is when a woman dies during child birth due to insufficient medical provisions required during child birth complications. It is astonishing to see that MMR (Maternal Mortality Rate) and development act as anti-goals in developing countries like India whereby actions taken by the government has been unable to prevent such medically preventable deaths too. Adding to this is the humungous challenge of poverty which directly confronts the health governance sector of the nation. ‘Health Governance’ is an allegory for everything which comes under the ‘well being’ that is a sum total of healthy state of body and mind to expedite improvement of human capacities. The World Health Organization (WHO), the directing authority for health within the United Nations (UN), now lists “fostering health security and strengthening health systems under health governance” as one of its core agendas (Global Health Governance, 2011). Every human being has the fundamental right to achieve highest standards of mental and physical health for which the government much ensure easy access, availability, good quality services and goods till the last mile. The citizens of a nation contribute to its socio economic development which is only possible if she or he is able to lead a healthy and happy life. “The right to health is central to ensuring human security and protecting people from “critical and pervasive threats to human lives, livelihoods and dignity, and to [enhancing] human fulfilment (Ministry of Foreign Affairs, Japan,2009).

Being a mother or motherhood is one of the most significant unmeasurable but most life-risking responsibilities of a woman. Simultaneously the joy it brings it is sadly the biggest killer in the world for women. It has been defined as an international public health crisis. “Over 350,000 women die each year from pregnancy related causes and 99% of these deaths occur in developing countries” (Horton, 2010). So it is not just the woman who suffers but the society as a whole, as families face the brunt of such huge losses. The health of a mother is directly proportional to the child itself both during pregnancy and post-delivery. Thus, the grave understanding of this situation was addressed by the United Nations as separate goals related to infant mortality rate (MDG 4) and maternal mortality rate (MDG 5) under the MDGS.  Women over the past have received little or nil attention as health itself was never an international concern. Adding to the gender disparities, women’s health was never taken into cognizance by nations largely. The Millennium Declaration acted as the first step that such eminence was abstracted towards global assertion of this matter. The need of the hour as this paper addresses is to galvanize all acts and actions at the earliest, to provide social protection to women and her right to happy and healthy life

Understanding the underlying elements of Maternal Mortality Rate – Literature review 

In a 2010, Report of the WHO, UNICEF, UNFPA and The World Bank, ‘Trends in maternal mortality: 1990 to 2008, ‘gave a shocking revelation that 63,000 of the estimated 3,58,000 deaths due to complications during pregnancy and childbirth worldwide occur in India. (Authored by the World Health Organization, UNICEF, UNFPA and The World Bank, 2010).

There is an increasing acknowledgement of women’s health and of her unborn foetus which directly has a profound effect on the overall wellbeing of the community and the nation as a whole.  The simple logic which can be adhered to is that a healthy mother leads to a healthy child. “Women in less developed countries have, on average, many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of maternal death is the probability that a 15-year-old woman will eventually die from a maternal cause. In high income countries, this is 1 in 5400, versus 1 in 45 in low-income countries” (WHO, 2023). India depicts similar traces whereby high mortality is caused by poor access to reproductive health care facilities such as antenatal and post-natal health care services, lack of access to skilled care during pregnancy, fear of reproductive infection due to unhygienic health centres or homes, death due to abortion or neglected or forced child birth. Poverty exacerbates the existing condition due to additional lack of resources or basic needs such as healthy meals, medications, poor nutrition, proper rest, workloads, domestic violence and lack of education and awareness. 

Indicators used to measure maternal health include skilled attendance at birth, contraceptive prevalence rates and maternal mortality and morbidity. Mondal (1997) studied Rajasthan using NFHS-1 (1992-93) data and found out that the main problem of underutilisation of services was embodied in the socio economic and cultural background of the care seekers. Kumar (1999) found out that the religion and cultural differences between Nagori Muslims and caste groups in the area were less important as far as reproductive health perspective and needs were concerned. Saha and Chatterjee (2000) found that many of the women did not have the knowledge of the services and almost 51.4 per cent of women felt that care was not necessary for a healthy motherhood. The study conducted by Bhatia and Cleland (1995) in the State of Karnataka observed that most of the public and private practitioners are Hindus, but Muslims were more likely to use ante natal care services. The higher caste Hindus generally remained confined to their homes while lower castes agriculture labourers have insufficient time for check-up. It was expected that due to social barriers Muslim women might seek less services but study showed that the reverse was true. Pandey et al (2004) have seen the effect of geographical factors on the utilisation of Ante Natal Care (ANC) services and found out that Uttaranchal differed in ANC utilisation and it can be attributed to difficult terrain. Ray et al., (2004) studied the social inequalities in health and nutrition in selected States of India. They found that Kerala, T. N, Goa and Himachal Pradesh have achieved near equality conditions as far as ANC is concerned. West Bengal, M.P. and Orissa reveal highest inequality between the social groups regarding accessibility to health services.

Large scale incongruities exist in the consumption of maternal care services due to large scale ethnic and cultural differences. This further confounds the view that health care services should develop taking care of the composition of the population where it has to be implemented. Various international studies across the world have revealed the direct co relation of usage of health services vis a vis the socio, ethnic, cultural disparities. Studies carried out in Africa have revealed that ethnic differences mark the utilization of health services; providing care to majority of poor black population was an enormous problem as they lived in dormitory cities and squatter settlements where children were being born and reared in overcrowded and disadvantaged circumstances. Rip and Hunter (1990) studied the community prenatal health care system of urban Cape Town , South Africa . Results have shown that black mothers have delivered proportionately more in clinics than racially mixed mothers, while the reverse was true for hospital based births. Black mothers had more of deliveries in clinics rather than hospitals. As society gets compartmentalized into different social groups, ethnic disparities guide worlds distribution of health care services within the nations. Niraula (1994) studied the hills of Nepal , whereby similar to caste divisions in India, the higher castes were the well off and hence availed major benefits in terms of health care as compared to the lower ethnic caste groups.

Fig 1: ESCAP/ADB/WHO Report 2010 Health Governance in the Asia Pacific

In figure 1 highlights the statistics related to skilled personnel amongst various countries across the globe.  Pakistan, Sri Lanka, Malaysia and Vietnam are relatively better placed than India with relation to availability of skilled personnel which has a direct impact on the MMR. India has the highest number of doctors but very weak service delivery to ordinary people which worsens its goals towards reduction of MMR. Magadi et al., (2000), discussed poverty as the major impediment in terms of adequate maternal health care in Sub Saharan Africa which is a similar concern in India as well. Another study by Rip and Hunter (1990) tried to showcase the importance of education in leading to better health care services, whereby better antenatal care was availed due to proper knowledge of the services. Education reflects the development of the cognitive skills and exposure to new ideas and modern institutions. It ends up influencing a women’s approach towards better curative and preventive health care facilities. Becker et al., (1993) observed that education was again an important predicator of prenatal care in urban and rural areas. The husband getting educated added further to the access of health services by the household over all. Education gives women a greater power over their circumstances, which eventually leads to greater consumption of health care and demanding one’s own rights as postulated by Caldwell (1981). 

But despite the attainment of economic status and increase in representation in work forces, a women’s decision making power with respect to their reproductive capacity still remains the same.  With the dominance of a patriarchal set up within the developing societies largely women tend to be behind the doors of the household. Thus, lower literacy levels completely make them nascent in terms of health care services. Indian households see large scale traditional household births due to the conservative thoughts of getting treated by strangers in hospital. This puts the mother at greater risk of morbidity due to absence of expertise and essential lifesaving services. 

Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in a suitable setting, where lifesaving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Thaddeus and Maine, (1994) illustrates the "Three delays" model; whereby three main inhibitors to health care service utilization exist:

1. Delay in deciding to seek care, the  

2. Delay in reaching an adequate health care facility and 

3. Delay in receiving adequate care at that facility.

The above review clearly identifies several underlying determinants that have impacted India’s position in striving towards its MDGS with respect to mother’s health. “Though India is close to attaining the goal set for the under-five mortality rate, it has missed the targets for infant mortality (39 per 1000 births in 2014 vs. targeted 27 for 2015) and maternal mortality (167 for 2011-13 vs. target of 109 in 2015) as concluded by UNICEF (2015). The valuation of progress towards the MDGs has recurrently showed that the poorest and those disadvantaged because of gender, age, disability or ethnicity are often bypassed.

MDG to SDG – The Road ahead Towards 2030

The SDGs are pledges to finish what the (MDGs) started in 2015. These goals were encompassed under the “Transforming our World: The 2030 Agenda for Sustainable Development’ on September 2015. These goals are ambitious enough to address the key problem areas of global development such as universal wellbeing across diverse socio- geographical, economic, cultural divisions and to simultaneously assimilate the economic, social and ecological dimensions of progress. These seventeen goals have 169 targets and 304 indicators that all members of the UN agreed to work upon for a better world.  Niti Ayog’s SDG Index 2.0 highlighted nutrition and gender equality as major focus area. 

As per the SDG Index score Kerala has achieved the best state record of MMR at 70 , followed by Himachal Pradesh and Tamil Nadu. Sadly, Uttar Pradesh and Bihar stand at the lowest levels even today (Niti Ayog, 2019). India needs to fix its basic health care concerns in the areas of HIV, tuberculosis, children under five are being born underweight and having to reach the estimated MMR are the drastic concerns currently under India’s developmental planning. The role of effective governance to tackle such grave situations involves the role of various stakeholders within the country. The research focuses at the seriousness of the issue of Indian public health governance and structure. Every maternal death globally sees its 20 per cent loss in India which is a very big threat. Proper surveillance systems within states, strong political commitments, reducing the private expenditure on health by every Indian, deficit of human resources, delays in availability and access to health care services are some of the key loopholes that the government needs to focus on. 

Conclusion 

As Koblinsky quoted “increased attention towards maternal and perinatal health ensures women's rights and agencies are acknowledged (Koblinsky et al, 2016). Various stakeholders need to collectively divert their efforts towards reducing the oppression of women at large.  Various international organisations have highlighted that women are more prone to disease and ill health due to large scale inequities and inequalities that are widespread. Studies by John Hopkins University outlined “women’s overrepresentation among the destitute and poor; early or forced marriages; unmet need for family planning; domestic and sexual violence; cultural and religious oppression; victimisation during disasters, wars, and civil unrest; lack of access to education; political disempowerment; social exclusion based on sex or race, ethnicity; and labour inequalities.” (John Hopkins, 2019). The continuum of care strategy identifies the relation of a healthy mother to a healthy child. An assimilated methodology by the international and national actors needs to be commenced. All health oriented policies need to structure itself within the human rights based framework whose core objectives are justice, equity and equality to women and children. The governance responses need to be revolutionary in nature as well as sustainable at the same from time. Effective monitoring and surveillance needs to highlight the red flags time to time to avoid delays of effective service delivery at all levels. High-quality health care needs to be available and affordable for all people, regardless of underlying social disadvantages. Measures of quality need to be disaggregated by stratifiers of social power—such as wealth, gender, or ethnicity—and quality improvements should explicitly include poor and vulnerable people to redress existing inequities” (WHO, 2015).

References

1. Bhatia JC & J Cleland,(1995) “Determinants of maternal care in regions of South India” health Transition Review 5: 127-142

2. Chatterjee S & KB Saha, (2000), “An overview of utilization of ANC services among Scheduled Castes of major states in India”: Anthropologist vol 2 (1):pg 37-42

3. Global Issues Cooperation Division Ministry of Foreign Affairs of Japan (2009)  “ The Trust Fund for Human Secuirty  For the “Human-centered” 21st Century 2009

4. Koblinsky M, Moyer CA, Calvert C, et al.  (2016 ) Quality maternity care for every woman, everywhere: a call to action. Lancet 2016

5. Kumar MU, (1999) “ Households , Kinship, & Access to Reproductive Health care among rural Muslims women in Jaipur” EPW, vol 34, 34-63

6. Magadi et al (2000), “ Frequency and Timming of Antenatal Care in Kenya : Explainning the variations between women of different communities” Social Science & Medicine 51: pg 551-561

7. Makerere University & Johns Hopkins University (2019) MU-JHU) Care Ltd., MU-JHU Research Collaboration, Kampala, Uganda. 

8. Maternal Mortality Report by UNICEF ( 2018).

9. Mondal SK,(1997), “Utilisation of Antenatal Services in Rajasthan:observations from NFHS” Journal of Family Welfare,43(3)pg 28-33.

10. Niraula BB (1994), “Use of Health services in Hill regions in Central Nepal” Health & Transition Review -4(2)pg 151-166.

11. Niti Ayog SDG India Index and Dashboard  https://sdgindiaindex.niti.gov.in/#/download

12. Pandey et al (2004), “ Maternal Health care services: Observations from Chattisgarh, Jharkhand & Uttranchal” EPW Feb 713-720.

13. Richard Horton, (2010)"Maternal Mortality: Surprise, Hope and Urgent Action," The Lancet 375.9726 (2010).

14. Rip & Hunter (1990) “The Community perinatal health care system of urban Cape Town , South Africa 2” Geographical Patterns, Social Science & Medicine: 30(1)pg 119-130.

15. Roy et al (2004) “Social Inequalities in Health and Nutrition in selected States” EPW 39, pg 677-683.

16. Thaddeus, S., & Maine, D. (1994). Too far to walk: maternal mortality in context. Social Science & Medicine (1982), 38(8), 1091–1110. https://doi.org/10.1016/0277-9536(94)90226-7UNICEF, Child mortality estimates- country specific under five deaths(2016)

17. WHO- WHO global strategy on people-centred and integrated health services. (2015)  http://www.who.int/servicedeliverysafety/areas/people-centred-care/global-strategy/en/

18. World Health Organisation (2023) “Maternal Mortality: Key Facts” https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.