Maternal mortality in India: causes and healthcare service use based on a nationally representative survey

Abstract

Background: Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India's 2001-2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states.

Methods and findings: The Registrar General of India surveyed all deaths occurring in 2001-2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10,041 all-cause deaths in women age 15-49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004-2006 SRS national MMR estimates of 254 deaths per 100,000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385-410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85-146). We estimated 69,400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states.

Conclusions: Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.

Figure 1. 2005 estimated proportion and number of maternal deaths by region.

Datasource: SRS 2001–3, SRS 2004–6 MMR and UN live birth and death estimates for India 2005 ^*Unweighted sample count of maternal deaths ^**Survey weighted, (95%CI), rounded to nearest 100th. MDS - Million Death Study. Low-income states Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan, Uttar Pradesh, Uttarakhand and Assam.

Figure 2. Cause of death distribution and estimation of annual number of maternal deaths by cause.

Datasource: Indian SRS 2001–3 data, SRS 2004–6 MMR and UN live birth and death estimates for India 2005. ICD-10 categorization of cause of death MDS - Million Death Study ^aUnweighted sample count of maternal deaths ^bSurvey weighted, (95%CI), rounded to nearest 100th. ^cIncludes ill-defined obstetric deaths (n = 205), antenatal and postpartum suicide (n = 24), vascular accidents (n = 16), and uterine inversion (n = 2). ^dIncludes ‘unanticipated’ anesthetic complications (n = 4). Compare with proportion of unweighted maternal deaths reported with RGI categorization: hemorrhage (38%, estimated total deaths for 2005 = 26 000), other (34%, total = 23 500), sepsis (11%, total = 7600), abortion (8%. total = 5500), obstructed labour (5%, total = 3400), and hypertensive disorders of pregnancy (5%, total = 3400) .

Figure 3. Proportion of highest healthcare sought by timing of direct maternal death.

x-axis: Survey weighted proportion of timing of direct maternal death (n = 919) with respect to the pregnancy: early termination (spontaneous or therapeutic), term antenatal complication (≥7 months), intrapartum, postpartum. y-axis: Highest healthcare sought at onset of complication leading to death: routine admission to health-facility/hospital for abortion or labour, emergency admission for complication, community consultation for complication, no facility-based healthcare utilization at time of complication.

Figure 4. Uptake of routine and emergency healthcare in poorer and richer states, by rural urban areas.

Datasource: Indian SRS 2001–3 data. Graphs A and B for subgroup of women who experienced spontaneous labour onset or arranged a medical abortion (n = 732) (i.e. omitting those for whom a complication arose prior to the need for of routine care). A:Skilled birth attendance comparison of rural and urban area of poorer states (p = 0.0022) and richer states (p = 0.0435) and B: Planned health-facility delivery comparison of rural and urban of poorer states (p = 0.0435) and richer states (p = 0.3061). Graphs C and D for all maternal deaths in the sample (n = 1096). C: Emergency transport comparison of rural and urban area of poorer states (p = 0.0036) and richer states (p = 0.2919) and D: Health-facility admission comparison of rural and urban area of poorer states (p = 0.0001) and richer states (p = 0.4135).