Achieving Millennium Development Goals 4 and 5 in India

Abstract

Please cite this paper as: Chatterjee A, Paily VP. Achieving Millennium Development Goals 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–59.

This review relates to achieving the Millennium Development Goals (MDGs), especially MDGs 4 and 5, by India by the year 2015. India contributes the maximum number of maternal deaths (68 000) to the global estimate of 358 000 maternal deaths annually. Infant mortality rate (IMR) is also high at 50 per 1000 (2009). Low budgetary spending on health, poverty, lower literacy, poor nutritional status, rural–urban divide and lack of trained workers in the health sector are cited as reasons for a high maternal mortality ratio and IMR. Increased spending by the Government of India on the health sector has started to show encouraging results. Recent assessments by world bodies like the World Health Organisation have given hope that MDGs 4 and 5 are achievable.

Background

India is a fast developing country, with an area of 3.2 million km² or about one-third of the area of the USA. It is the biggest democracy in the world along with extremes of diversity in all spheres of life. Its population of 1.21 billion is second only to that of China.¹ The population was only 350 million in 1947, when India gained independence.

Maternal and child health statistics

The total number of maternal deaths of 68 000 per year is the highest of any country.² The total fertility rate was 2.7 in 2005–06³ and the percentage of women of reproductive age was 48.9.³ The adolescent birth rate was 45.9 per 1000 women in 2005–06.³ The maternal mortality ratio (MMR) was estimated as 230 in 2008.²

On the child health front, the data are again alarming. The perinatal mortality rate was 48.5 per 1000 live births in 2005–06.³ The latest available figures indicate that the infant mortality rate (IMR) is 50 per 1000 live births and the under-5 mortality rate is 66 per 1000 in 2009.⁴

The latest census report released on 31 March 2011 shows a fall in the decadal growth rate by 4% (from 21.54% to 17.64%) and a rise in the total literacy rate by 9% (from 65% to 74%) with literacy of males at 82% and of females at 65%.¹

Specific (numbered) Millennium Development Goal (MDG) 4 and 5 targets for India

Reduction in maternal mortality

Hard data on the actual MMR for India are not available. The results given here are based on sample surveys or estimates (Table 1). The MMR for India in 1992 was estimated to be 437 per 100 000 live births with a gradual reduction to an estimated 230 per 100 000 live births in 2008.² The target for 2015 is 109 per 100 000, but at current levels of decline the MMR is expected to reach 135 per 100 000 by 2015.⁵

Table 1.   MDG 5A: reduction in maternal mortality

	1990	1995	2000	2005	2010	2015
SBA, skilled birth attendant. Source: National Family Health Survey, Coverage Evaluation Survey (CES).
Maternal mortality ratio	437 (1992)	407 (1998)	301 (2001)	254 (2006)	230 (2008)	Target 109 (expected to achieve 135)^5
Proportion of births attended by skilled health personnel	25.5% (1992–93)	No data	39.8% (2002–03)	48.8%	79% (Inst. del. 76% + 3% SBA home del.) (CES 2009)^6	Expected to achieve around 90%

The place of birth (at home or in an institution) and the type of assistance available (untrained or trained) have improved over the years. In 1992–93 only 25.5% of births were attended by skilled health personnel whereas in 2009 this was 79%⁶ and expected to reach 90% by 2015. In India, attendance by skilled health personnel is not synonymous with institutional deliveries as it includes deliveries conducted at home by trained health workers (see Table 1).

Access to reproductive health

The data relating to the period 1990–2010 given in Table 2 show an improvement in all these areas, albeit rather slow. In 2009 about 90% of women had at least one antenatal visit.⁶ The unmet need for family planning was only 12.8% in 2005–06.³

Table 2.   MDG 5B: achievements in access to reproductive health

	1990	1995	2000	2005	2010	2015
Source: National Family Health Survey, Coverage Evaluation Survey.
Contraceptive prevalence rate	43.5 (1991)	No data	46.9 (2000)	56.3 (2006–07)	No data	No data
Adolescent birth rate	76.02 (1991)	54.02 (1997)	51.24 (2000)	45.9 (2005)	No data	No data
Antenatal care coverage (at least one visit and at least three visits)	64.6% 43.9% (1991–92)	No data	66% 44.2% (1998–99)	76% 52% (2005–06)	89.6% 68.7% (2009)	No data
Unmet need or family planning	19.5% (1992–93)		15.8% (1998–99)	12.8% (2005–06)	No data	No data

An indirect indicator of child health is the proportion of 1-year-old children immunised against measles. These are given in Table 3. The targets of 38 per 1000 for the under-5 mortality rate and 26.7 per 1000 for IMR are difficult to achieve.

Table 3.   MDG 4: reduction in child mortality between 1990 and 2015

	1990	1995	2000	2005	2010	2015
SRS, Sample Registration System. Source: National Family Health Survey 3 (NFHS-3), Coverage Evaluation Survey 2009 commissioned by UNICEF.
Under-5 mortality rate	112 (1990)	No data	No data	85 SRS (2004)	66 SRS (2009)^28	Target 38
Infant mortality rate	80 (1990)	No data	No data	57 (NFHS-3, 2005–06)	50 (CES 2009)	Target 26.7
Proportion of 1-year-old children immunised against measles	32.7% (1990)	No data	No data	59% (NFHS-3, 2005–06)	74.1% (CES 2009)	No data

Continuum of care

Antenatal care

In India ‘complete antenatal care’ is considered to include three antenatal care visits, two tetanus toxoid injections and 90 doses of iron and folic acid (IFA) tablets.⁷ Women who do not receive complete antenatal care are usually older women, women having children of higher birth orders, scheduled tribe women, women with no education and women in households with a low wealth index.³ These differentials suggest that improving the coverage of antenatal programmes requires special efforts to reach older and higher-parity women and women who are socio-economically deprived. There is region-wide disparity in antenatal care. While states like Kerala, Tamil Nadu, Karnataka and Goa have near universal utilisation of antenatal care, a state like Bihar has only 34% utilisation. Overall, in India 75% of pregnant women received at least one antenatal visit, while 51% received three antenatal visits during 2007–08. This went up to 89.6% and 68.7% respectively in 2009.⁶ As seen in Table 4, there is a gradual but definite improvement of antenatal care services over the years.

Table 4.   Antenatal care indicators for India

	NFHS-1 (1991–92)^28	NFHS-2 (1998–99)^29	NFHS-3 (2005–06)^3			CES 2009^6
			Rural	Urban	All India
NFHS, National Family Health Survey; CES, Coverage Evaluation Survey.
Mothers who had at least one antenatal visit (%)	64.6	66	72	91	76	89.6
Mothers who had at least three antenatal visits	43.9	44.2	43.7	74.7	52	68.7
Mothers who take iron and folic acid for 90 days or more (%)	No data	No data	18.8	34.8	23.1	31
Mothers who received tetanus toxoid vaccine (minimum of two doses) (%)	53.8	66.8	72.6	86.4	76.3	86.9
Mothers who received complete antenatal care	No data	No data	10.2	23.7	15	26.5

Intrapartum care

Since independence in 1947, there has been a paradigm shift in the Government of India’s approach to provision of intrapartum care. Initially rural health services were established with primary health centres (PHCs) and subcentres. The PHCs had a trained nurse midwife but the subcentres were staffed by locally recruited women trained only for a short period. The latter were later recruited as regular staff called the auxiliary nurse midwife (ANM). However, intrapartum care was provided mostly by untrained traditional birth attendants (TBAs). From 1992 to 1996 these TBAs were trained under the scheme called Child Survival and Safe Motherhood⁷ supported by the World Bank and United Nations Children’s Fund (UNICEF). However, later it was realised that trained TBAs did not improve the intrapartum care and in 2005 the emphasis was put on promoting institutional delivery by a skilled birth attendant (SBA). Table 5 shows the increase in births attended by skilled health personnel. These include deliveries in institutions and those at home attended by trained health workers. A trained health worker can be a doctor, nurse, midwife, ANM or a trained TBA. The coverage evaluation survey of 2009⁶ has reported 76% were institutional deliveries and 3% home deliveries by an SBA.

Table 5.   Status of delivery and postnatal care in India

	NFHS-1 (1991–92)^28	NFHS-2 (998–99) ^29	NFHS-3 (2005–06)^3			CES 2009^6
			Rural	Urban	All India
Proportion of birth attended by skilled health personnel (%)	35.1	42.4	37.4	73.4	48.8	79
Institutional deliveries (%)	26.1	33.6	28.9	67.4	40.7	76
Mothers who received postnatal care from a doctor/nurse/LHV/ANM/other health personnel within 2 days of delivery for their last birth (%)	No data	No data	28.6	61	36.8	NA

Under the National Rural Health Mission (NRHM) launched in 2005, there was an increase in cash incentives for institutional deliveries. Many state governments (e.g. Tamil Nadu) added further incentives to promote institutional deliveries and such states achieved a drastic increase in institutional deliveries.⁸

The percentage of births assisted by a doctor/nurse/lady health visitor (LHV)/ANM/other health personnel trained in emergency/essential obstetric care (EOC) went up gradually from 35.1% in 1991–92 to 42.4% in 1998–99, 48.8% in 2005–06 and 79% in 2009.

Postnatal care

Those women who delivered in institutions or who received care from a doctor/nurse/LHV or ANM within 2 days of delivering at home are considered to have received postnatal care. Data for the period 2005–06, collected during the National Family Health Survey (NFHS-3),³ are given in Table 6. There was wide variation between urban and rural settings.

Table 6.   Indicators of family planning services

Indicators	NFHS-3 (2005–06)^3
Total unmet need for family planning (%)	13.2% of women of reproductive age (15–49) who are married or in consensual union
Unmet need for spacing	6.3%
Unmet need for limiting	6.8%
Contraceptive prevalence rate (current use of contraceptive methods)	56% of currently married women aged 15–49

There is no structured pattern for postnatal care in the country as a whole even now. This is an area that needs urgent attention. A new trend evolving, after the increase in hospital deliveries under the Janani Suraksha Yojana (JSY) scheme of the NRHM, is that mothers get discharged very soon after delivery after receiving their cash incentives for delivering in a health facility. This deprives them of the postnatal care for mothers and essential newborn care.

Family planning

Contraceptive use in India is around 56% among currently married women aged 15–49. The fertility rate also has declined to 2.7 in 2005–06 with many states having already achieved the replacement fertility level of 2.1. Female sterilisation accounts for two-thirds of contraceptive use. But still the unmet need for family planning is estimated to be 13.2%. This is in addition to an unmet need for ‘spacing’ of 6.3% and unmet need for ‘limiting’ of 6.8%. All these figures refer to married women (Table 6).

Newborn care

In 2008, 1 million neonates died in India.⁹ This constituted about 55% of the under-5 mortality. The main causes were prematurity (13%), birth asphyxia (10%) and various infections (19%). Neonatal deaths are directly influenced by the midwifery care received at birth for causes such as birth asphyxia and prematurity. Breastfeeding practices also influence the number of neonatal deaths. The estimated neonatal mortality rate for India in 2008 was 35 per 1000 live births.¹⁰ The target laid out in the National Plan of Action for Children 2005 was 18 per 1000 live births by 2010.¹¹ This target was not achieved.

Care for the children aged under five

An estimated 1.8 million children aged under 5 years died in 2008. This includes 1 million neonatal deaths. The under-5 mortality rate has shown a steady decline from 112 in 1990 to 85 in 2005–06³ and 66 in 2009.⁶ Over the same periods the infant mortality was 80 in 1990, 57 in 2005–06 and 50 in 2009⁶ (Table 7). The MDG 4 target for under-5 mortality is 38 per 1000 live births by 2015. India is very unlikely to achieve the target at the present rate of decline in under-5 mortality.

Table 7.   Present scenario of child health in India

MDG target	Health indicator	1990	2005–06	Recent
SRS, Sample Registration System; CES, Coverage Evaluation Survey. **NFHS-3 (2005–06)^3.
T 4:113	Under-5 mortality rate	112	85**	66 SRS 2009^24
T 4:114	Infant mortality rate	80	60^12	53 SRS 2009^24
T 4:115	Proportion immunised for measles	32.7%	59%**	74.1% CES 2009^6

Causes of maternal, newborn and child mortality and morbidity

Medical causes of maternal death

The leading medical causes of maternal death are haemorrhage 37%, sepsis 11%, complications of abortion 8%, hypertensive disorders 5% and obstructed labour 5%.¹² But the proportion of these causes varies between states and regions. For example, the leading causes of maternal death in the state of Kerala, where confidential review of maternal deaths is being done, are haemorrhage 19.8%, hypertensive disorders 13.2%, amniotic fluid embolism 9.7%, venous thromboembolism 5.8% and heart disease 9.4%.¹³ Under the heading of haemorrhage, postpartum haemorrhage is the leading cause.

Non-medical factors contributing to maternal deaths

While searching for the non-medical factors contributing to maternal death it is prudent to consider the vastness and the diversity of India. India is about one-third the size of the USA and with respect to area many of its states are the same size or larger than many sovereign countries of western Europe. Also, for several years since achieving independence in 1947, international political situations have forced India to divert much of her hard earned money to defence purposes, rather than towards the health of her own people. Factors contributing to poor maternal health are as follows.

Political will

Health is primarily a state issue as per the Indian constitution. This potentially causes conflict between the centre and the states, where two different or opposing political parties may be in power.

Health economics

Of the total health expenditure of 6.1% of gross domestic product in 2002, the government’s share was only 1.3% whereas private expenditure was 4.8%³². This means that only 20.3% of expenditure on health comes from the government; 77.4% is from the patient’s pocket. In the USA public health expenditure is around 50% and in western European countries it is over 80%.¹⁴ Contrary to popular belief, the contribution from international funding agencies like WHO and UNICEF on health was a meagre 2.3%.¹⁵ To make matters worse, there is very little insurance coverage available for maternity services in India.

The higher cost of a hospital delivery makes a home delivery the preferred option for the poor. About 18% of women and husbands of those who delivered at home consider cost of delivery at health facilities too high to afford.⁶ Realising this the Government of India has come forward to provide cash incentives for hospital deliveries since 2005 through the JSY scheme under the NRHM.¹⁶

Infrastructural problems

Private and government (public) hospitals coexist in most places, but the poor depend on the health centres run by the government because they provide a free service. But these centres have drawbacks including a perpetual shortage of funds, equipment and skilled staff. There are not enough government centres, which also leads to poor service provision.

The doctor:people ratio in India is 1:1722 (http://www.financialexpress.com/news/doctorpopulation-ratio-stands-at-11-722/139534/. Accessed 12 July 2011)³⁵, compared with the doctor:people ratio of the UK which is 1:416.¹⁷ There are about 1 million vacancies for nurses in India. Doctors from India (56 000) account for the largest share of migrant health workforce in Organisation for Economic Co-operation and Development countries.¹⁸

Organisational failures

This is one of the main causes of several delays in accessing maternity care in India:

• • 
   Because of low economic power coupled with illiteracy, there is always delay in seeking help during maternal and neonatal emergencies.
• • 
   Lack of timely availability of transport—car or ambulance—leads to a delay in reaching the health centres in time. Ready cash to pay for transport is not usually available and this worsens the situation, even when transport is available.
• • 
   Even when the patient reaches the desired health centre, overcrowding, lack of equipment and other medical supports coupled with a chronically understaffed environment delays emergency management.

Issues of management in the health system are also important. India has only three technical officers for maternal health at the national level, and there are no maternal health directors in most states. Lack of management capacity in the health system has led to poor quality services and slow progress.¹⁹

Socio-economic determinants

• • 
   Low literacy rate: The literacy level of women in the reproductive age group (15–49 years) in India is just 55%. In all, 41% of women and 18% of men have never been to school.³ Illiteracy in mothers doubles the IMR. The rate of antenatal care and institutional delivery is higher in women who are educated. The literacy level of women in various states influences performance in maternal health. Thirty-seven percent of illiterate pregnant women did not receive any antenatal care whereas the corresponding figure for women with more than 12 years of education was only 1.7%. Educated women are more likely to take a full course of IFA, receive tetanus toxoid and have an institutional delivery.
• • 
   Poverty: Twenty-seven percent of the Indian population live below the poverty line. Poor pregnant women are less likely to receive proper nutrition and maternal care. For pregnant women in the lowest quintile of wealth index, 41.3% did not receive any antenatal care and only 13% had institutional delivery.³
• • 
   Poor social status of women: Any decision making regarding health care during pregnancy is usually taken by the husband or his family and not the pregnant woman. Forty-one percent of women did not get any antenatal care because their husband/his family did not think that it was important or did not allow women to access antenatal care.³
• • 
   Reduced awareness of health care needs: There is reduced awareness about the need for antenatal care and need for delivery in a health facility. Seventy-two percent of women who did not deliver at a health facility did not feel it was necessary to deliver at a health facility.³
• • 
   Age of marriage: Early marriage is an age-old tradition in India. Sixteen percent of girls between 15 and 19 years are already pregnant. The IMR is 77 in teenage mothers, while it is 55 in the post-teenage group.³ Pregnancy in teenage girls is twice as common in rural as in urban areas in India.
• • 
   Health and nutritional status of women: Poor nutritional status of women leads to increased maternal mortality. The percentage of women with anaemia is 55.6%.³ Moreover only 23% of pregnant women take IFA for 90 days and 58% of pregnant women are found to be anaemic.

Ignoring evidence

The concept of EOC, essential to save mothers with complications of pregnancy or childbirth, was not universally implemented in India until recently. It has been recognised that EOC is one of the most cost-effective strategies for reducing maternal deaths anywhere in the world Averting Maternal Death and Disability (AMDD Network Conference, Kuala Lumpur).²⁰ However, this was not implemented in India due to lack of focus and limited management capacity. Even today the Government of India does not systematically monitor how many EOC facilities are fully functional. Most of the first referral units have no staff to offer EOC on time. The NFHS-3 (2005–06) has shown an institutional delivery rate of only 39%.³ Since then there has been an increase in institutional deliveries due to JSY; however, a substantial percentage of births are still domiciliary and India needs to provide the option of SBA at the community level. Recently, under NRHM there has been a greater focus on strengthening EOC services.

For many years, India lacked a focus on developing a skilled professional midwifery cadre, which has led to persistent dependence on TBAs for deliveries leading to high maternal deaths. In the past, the Indian government has spent a lot of money and time on TBA training, despite the knowledge that TBAs cannot reduce MMR. The limited resource allocations have even been diverted from maternal health. A lack of qualified midwives in India is a major human resource constraint for providing locally accessible, skilled delivery care for rural women. This has led to a questionable quality of health care, particularly maternal health care. Among women receiving antenatal care for their most recent birth, 28% had no abdominal examination, only 64% had their blood pressure checked, and 63% had their weight measured.³ MBBS doctors often refuse to work at the village level, mostly due to lack of social and medical infrastructure at rural facilities.

Causes of under-5 mortality

The major causes of under-5 mortality, other than neonatal mortality, are pneumonia 11%, diarrhoea 11% and other infections (see Table 8).

Table 8.   Causes of under-5 mortality in India⁹

Causes	Proportion (%)
Neonatal causes	55
Acute respiratory disease	11
Post neonatal diarrhoeal diseases	11
Malaria, HIV, AIDS	1
Measles	4
Injuries	3
Pertussis	5
Others infections	6
Other diseases (non-communicable)	4

Malnutrition

About 30% of live births are of low birthweight (<2500 g).²¹ Of children under 5, 43% are underweight (weight for age <2 Z score). A major cause of malnutrition is poverty and lack of adequate food. Only 33% of children attend Anganwadi (nursery run by the government), of which only 26% receive supplementary food from the nursery.

Low immunisation coverage

According to the NFHS-3,³ only 44% of children are fully immunised by the age of 2. About 5% of babies aged 6–23 months did not receive any immunisation. Table 9 shows the latest status of immunisation coverage. Immunisation coverage is found to be higher in the higher (compared to lower) socio-economic groups. In scheduled castes, immunisation coverage is still lower. Table 10 shows immunisation status by wealth quintiles.

Table 9.   Immunisation coverage for various vaccine-preventable diseases⁶

Vaccine	Coverage (%), CES 2009
DPT, diphtheria pertussis tetanus; OPV, oral polio vaccine.
BCG	86.9
DPT-3	71.5
OPV-3	70.4
Measles	74.1

Table 10.   Immunisation status by wealth quintile⁶

Wealth quintile	Percent immunised
Lowest	47.3
Second	61.6
Middle	66.4
Fourth	70
Highest	75.5

Diarrhoeal and acute respiratory diseases

Diarrhoeal and acute respiratory diseases are major causes of under-5 mortality (Table 8); 1.7 episodes of diarrhoea occur per child in a year in India. Only 60% of children with diarrhoeal disease are taken to a health facility.³ Thirty-nine percent are treated with oral rehydration therapy, including 26% receiving oral rehydration solution prepared from packets and 20% given gruel. More than 25% of children with diarrhoea did not receive any type of treatment at all. Sixteen percent received antibiotics. Eleven percent of deaths of under-5s were due to acute respiratory infections.⁹ Seventy percent of children with acute respiratory infection were taken to a health facility.³

Neonatal mortality

The causes for neonatal mortality are given in Table 11. The death of a baby within 28 days is considered a neonatal death. Preterm birth leads the list with severe infections and birth asphyxia closely following. In 2008, neonatal mortality rate was 35 per 1000 live births.¹⁰ The goal was to achieve a neonatal mortality rate of 18 per 1000 live births in 2010 as per the National Plan of Action for Children.

Table 11.   Major causes of neonatal mortality in India²²

Preterm birth + low birthweight	33%
Severe infections	27%
Birth asphyxia	19%

Infant mortality in India

The number of children dying in the first year of life per 1000 live births is taken as the IMR. In 2009, India’s IMR was 53 against a national goal to attain rates of less than 30 by 2010.²² Girls and those living in rural areas have higher IMR. Mother’s age and literacy also influence the IMR: it is higher where mothers are illiterate and aged <20 or more than 40. Scheduled castes and tribes have higher IMRs. When there is less than 2 years of spacing between children, the IMR goes up. About 30% of live births are low birthweights (<2500 g) and this is strongly associated with higher IMRs.²³

National strategies to address MDGs 4 and 5

National Population Policy (NPP) 2000

The National Population Policy²² was declared by the then Prime Minister in the year 2000. The key ideas were to stabilise the population of India by 2045. It was also envisaged to reduce India’s MMR to around 100 by 2015 by achieving at least 90% institutional deliveries and 100% deliveries attended by a SBA, even if these deliveries take place at home.

Tenth 5-year Plan 2002–07

This plan extended the scope and work formulated in NPP 2000, especially in the field of maternal health (http://www.planningcommission.nic.in/plans/planrel/fiveyr/welcome.html. Accessed 12 July 2011). The skills of the birth attendants were improved by upgrading the training of all health personnel, so that they could become competent SBAs. A standard format antenatal care card was introduced. All attempts were made to fill in the gaps with regard to Community Health Centres and first referral units to improve both antenatal and postnatal care. The required number of core specialists were deployed. Facilities for emergencies in Community Health Centres were improved. Availability of anaesthetists where needed and access to blood banks were also organised.

11th 5-year Plan (2008–12)

This 5-year plan promises to raise the sex ratio in India for the age group 0–6 years to 935 by 2011–12 and to 950 by 2017, to reduce the total fertility rate in the whole country to 2.1 and to reduce anaemia among women/girls by 50% by the end of 2012 (http://www.indianofficer.com/forums/indian-economy/2497-theme-indian-5-years-plan.html). This plan also aims to reduce the IMR to 28 per 1000 births and the MMR to 100 per 100 000 births. It also wants to reduce malnutrition for the age group 0–3 years to half of its present level.

State initiatives in helping to achieve MDG 5 in India

Reproductive and child health (RCH) programme

Holistic target-free approaches taken under RCH1 include ensuring EOC is available to all women who need it. In addition medical termination of pregnancy and manual vacuum aspirator were promoted extensively after providing authenticated training to the medical doctors. Control of reproductive tract infections (RTIs) and sexually transmitted diseases was given due importance and properly explained to all patients especially after medical termination of pregnancy procedures. Immunisation is almost a continuous process in India, even in the remote villages, after extensive door-to-door campaigns were held. The Government of India has vowed to make sure that all children are immunised and on time. Currently there is an easy flow of essential drugs and equipment kits in all health centres.

Under NPP

Further initiatives taken include RCH camps for remote areas, for the weaker districts and the urban slums. Regular training of ANMs and ensuring EOC services are accessible to all families below the poverty line at recognised private facilities are also done. Postpartum care in the community has been strengthened.

More recent strategies

Social franchising as public–private partnership

Arguments in favour are that at present only the public sector is providing a good quality of RCH services to all which is not a feasible or sustainable proposition in India or in South Asia. In India nearly eight out of ten patients pay the medical bill out of their own pocket. Most people do not have even minimum health insurance coverage.¹⁵ Medical insurance is still in its infancy, particularly in rural areas. Engaging the private sector in quality RCH services at affordable prices will cover all, especially the low income group. Social franchising has been an effective public–private partnership in creating access to quality RCH services worldwide, similar to Greenstar of Pakistan³³ and the Well Family Midwife Clinic of the Philippines.³⁴

Institutional deliveries to address prevention and treatment of postpartum haemorrhage

At the national level it was realised that the most effective way to tackle the problem of postpartum haemorrhage was to emphasise the need for institutional deliveries. The NRHM adopted this as a top priority and introduced the JSY to give cash incentives for institutional births. There was the obvious need to increase the number of hospitals to accept this additional patient load. A public–private partnership was promoted and hospitals in the private sector were accredited to accept such cases. Under the Chiranjeevi Project, the hurdles that were present for transferring funds to the private sector were removed. Emergency transport also needed to be strengthened and a network of ambulances was established. In many states, free transport for obstetric emergencies was arranged.

At present the plan is to increase the personnel available in the hospitals and to train them in proper conduct of labour including active management of the third stage of labour and emergency obstetric care.

The Government is giving top priority to upgrade the community health centres to first referral units where the signal functions of EOC will be available. However, shortage of staff is delaying the effective functioning of the scheme.

Strategies to achieve MDG 4 in India

The flagship project of the Government of India to achieve MDG 4 is the Integrated Child Development Services scheme.²⁵ It was started in 1975 but was up-scaled to achieve the MDGs, especially MDG 4. The main aim is to improve the nutritional and health standards of children aged 0–6 years and to enhance the capability of the mother to look after the normal health of the child. It aims to achieve the following objectives:

• • 
   improve household caring practices for newborn care and infant and young child feeding;²⁶
• • 
   improve routine immunisation to achieve 100% fully immunised by 1 year of age, and five doses of vitamin A by 3 years of age;²⁶
• • 
   integrate management of neonatal and childhood illnesses;²⁶
• • 
   appropriate management of malnourished children;
• • 
   train ANMs, Anganwadi workers and community volunteers on infant and child feeding practices;
• • 
   newborn care facilities to be made available in all comprehensive emergency obstetric and newborn care and basic emergency obstetric and newborn care institutions;
• • 
   strategy to improve household practices, breastfeeding, child feeding, recognition and care of low birthweight babies; timely referral, including improved recording of birthweights and prevention of childhood anaemia.

Programmes and policies to implement strategy

National programmes for maternal health have stressed the importance of universal antenatal care plus operationalising facilities which can provide EOC, focused antenatal care, birth preparedness and complication readiness, SBAs, and care within the first 7 days after delivery; these are the important factors that can help reduce maternal mortality in India and are major goals of the Health Departments in India. The focus has shifted to more institutional deliveries, operationalising first referral units throughout the country and initiation of the JSY (National Maternity Benefit Scheme) under the Rural Health Mission programme.

National Rural Health Mission

This programme was started on 5 April 2005 and is to continue until 2012. It is a Government of India programme with all India operation but with an emphasis on eight Empowered Action Group states, eight northeastern states and Himachal Pradesh, Jammu and Kashmir, thus totalling 18 states. The Empowered Action Group states are Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chattisgarh, Bihar, Jharkhand, Rajasthan and Orissa. The northeastern states are Assam, Meghalaya, Arunachal, Manipur, Mizoram, Nagaland, Tripura and Sikkim.

The aim of the NRHM is to create affordable, accessible, accountable, effective and reliable health care via the Accredited Social Health Activist (ASHA) who covers a population of 1000. The 2011–12 budget allocation for NRHM has been augmented by Rupees 2500 Cr (1 Crore = 10 million).

The functions of NRHM include:

• • 
   to increase facilities for institutional deliveries and emergency obstetrics and neonatal care
• • 
   all CHC/PHC to have around the clock services, to manage common obstetric complications
• • 
   to ensure access to safe blood at district hospital and first referral units
• • 
   EOC training and anaesthesia training for MBBS doctors

Janani Suraksha Yojana (JSY) (2005)

Protect the Mother scheme, this is an incentive based Government of India programme which has substantially increased institutional deliveries (Figure 4). Features of JSY include early registration, micro birth planning, referral transport (home to institution), institutional birth, post delivery visit and reporting, family planning and counselling, and behaviour change communication (BCC) to promote institutional deliveries.

Figure 4.  

Micro birth planning refers to the instructions given to the staff under JSY. They are required to register antenatal cases within 12 weeks, assist in disbursing the incentives, carry out various examinations and investigations and plan the delivery care. A variety of assistance packages are given through this scheme (Table 12). Around $34 extra is given if a caesarean section is needed or for management of complications requiring the service of private professionals. Incentives are given for two live births only.

Table 12.   Assistance package (US$) in JSY

Category	Rural		Urban
	Mother	ASHA	Mother	ASHA
Low performing states	28	12	20	4
High performing states	14	4	12	4

Gujarat Chiranjeevi Yojana Scheme (CY)

The CY was introduced by the Government of Gujarat state to increase institutional deliveries. This is done by providing financial protection to families below the poverty line and covering their out-of-pocket costs incurred on travel to reach the healthcare facility. The scheme also provides for financial support to the accompanying person for loss of wages. In the last 4 years, 450 000 deliveries of women below the poverty line have been carried out under this scheme. It is heartening to note that this scheme has won the Asian Innovation Award from Wall Street in Singapore.

Prior to the introduction of CY, the MMR for Gujarat was 218 per 100 000 live births and the neonatal mortality rate was 40 per 1000 live births. Current rates are shown in Table 13. A similar scheme has been set up on a franchised model in the State of Uttar Pradesh since 2008, to include 25 districts, mostly on eastern Uttar Pradesh.

Table 13.   Achievement of Chiranjeevi Yojana scheme

Total deliveries	Expected maternal deaths in absence of the scheme*	Maternal deaths reported under CY	Expected maternal life saved under CY	Expected newborn deaths	Newborn deaths reported under CY	Newborn saved
*Assumptions for expected maternal deaths.
176 293	384	32	352	8462	559	7903

Tamil Nadu model

Improving the whole environment and the quality of care in PHCs leads to a welcoming health centre. A cash payment of Rs. 6000 is offered to poor women (below the poverty line) for their nutrition and delivery-related expenses. The state government has also established a limited number of facilities for providing comprehensive emergency obstetric and neonatal care. All efforts are made to make these fully functional and able to provide a round the clock service. Arrangements have been made for training of medical officers in anaesthesia and in caesarean section. Death reviews are done for any maternal or neonatal death. Efforts continue in an attempt to solve the chronic problem of lack of trained doctors and midwives. All essential drugs are made available along with easy access to cross-matched blood and timely transport.

Emergency ambulance (phone 108) services

Eleven states of India have started rapid, effective ambulance services, which have a central calling system operated by IT professionals and also managed by them. They have state-of-the-art equipment for coordinating the ambulance providers and the care provider with the patient in need of emergency transfer. These are very useful and cost-effective services. Most importantly, this system saves lives.

Achievements to date

The overall average rate of MMR decline during the period 1997–2003 has been 16 points per year (Fig 2). At this rate of decline, the goal of 109 per 100 000 live births by 2015 may be difficult to achieve. Under the prevailing conditions, the MMR would be around 231 per 100 000 by 2012. But recent trends and projections on MMR in India, using data from the Registrar General of India, when projected to 2015 and based on the average annual rate of reduction between 1997–98 and 2004–06 shows that the expected MMR by 2015 will be around 135 instead of 109.⁵Figures 2 and 3 show the achievement.

Figure 2.  

Figure 3.  

Challenges and opportunities

Challenges that will need to be addressed in the coming years include the following.

• • 
   Enhanced inclusion. Two important groups—poor women and adolescents—need to be brought into the fold of reproductive health services through geographic and household targeting and clearly directed outreach activities. Increasing social and gender sensitivity among providers, managers and policymakers is essential to achieve this inclusion, as well as the supply and demand improvements noted below.
• • 
   Improve supply. Enhancing the supply of services for all stages of the reproductive life cycle, particularly combatting unsafe abortion, nutrition counselling, focused antenatal care, perinatal care, RTI/ Sexually Transmitted Infections (STI) diagnosis and treatment and increasing the availability and quality of frontline female health workers.
• • 
   Increase demand. It will be important to increase demand for several services that are provided but under-utilised, such as antenatal care, IFA, institutional deliveries and safe abortion services with family planning.
• • 
   Reform the health sector for reproductive health. Decentralised planning and resource allocation, vastly improved human resource development and financing improvements are all important and need to be addressed in the coming years.

Why maternal mortality is declining slowly in India

Technical/management analysis

Starting from 1966 until about the early 1980s maternal health was neglected, mostly due to the focus on family planning initiatives.¹⁹ Moreover, more reliance was placed on proven ineffective interventions like the high-risk approach of antenatal care and expensive but ineffective training of TBAs. Further neglect of maternal health was due to a focus only on child survival, universal immunisation and iron and folic acid tablets. ANMs and medical officers were made more accountable for target-oriented programmes such as family planning and immunisation. The deliveries conducted by PHC/subcentre staff were not monitored. As there was no monitoring of the MMR there was no recognition that the MMR was not reducing. There were only three technical managers at the national level, none specifically at the state level for maternal health. Although there was a clear policy intention, there was no proper strategy, no monitoring at any level, no measurement mechanism of outcomes and no review.

Will the MDG 4 and 5 targets be reached?

At the present rate of fall in maternal and child mortality, it does not seem possible for India to achieve MDG 4 and 5 by 2015 (fig 1). However, there are 4 years remaining, and with concerted efforts change is possible. This needs commitment from the political leaders and determined action from the administrators. The possibility of achieving each of the targets is shown in Table 14.

Figure 1.  (RGI - Registrar General India). Reproduced with permission from Elseiver. VK Paul VK, Singh Sachdev H, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, Sreenivas V, Sundararaman T, Govil D, Osrin D, Kirkwood B. India: Towards Universal Health Coverage 2 Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet 2011; doi:10.1016/S0140- 6736(10)61492-4.

Table 14.   Possibilities of achieving the MDGs in India

	Unlikely	Potentially	No data
Target 5A: reduce maternal mortality by three-quarters between 1990 and 2015
Maternal mortality ratio		May be possible
Proportion of births attended by skilled health personnel		May be possible
Target 5B: achieve universal access to reproductive health by 2015
Contraceptive prevalence rate		Possible
Adolescent birth rate	Unlikely
Antenatal care coverage (at least one visit and at least four visits)	4 visits unlikely	1 visit possible
Unmet need or family planning		Possible
Target 4: reduce child mortality
Under-5 mortality rate	Doubtful
Infant mortality rate	Doubtful
Proportion of 1-year-old children immunised against measles		Possible

Conclusions

The crucial question is ‘Will India achieve MDGs 4 and 5?’ One has to take into account the diversity of the country in many respects—political, geographic, economic, administrative, religious and cultural. There are areas which have already achieved the national targets specified in MDGs 4 and 5. In contrast, vast areas, especially in the northern belt, are far behind. India is widely recognised as an economic superpower but spending on health is still much lower than in the developed countries. Gender discrimination is a major factor even though at present the country has a woman president, speaker of parliament and chief of the ruling party. The rural–urban divide with lack of good quality health care in rural areas is a difficult obstacle to overcome. Empowerment of women in decision making is urgently needed. Otherwise the sentiments expressed by Professor Fatallah, the past president of the International Federation of Gynaecology and Obstetrics, will prove right. He said ‘Society has not yet decided whether it is worth spending (time/money/energy) on a woman’s life’. Lack of trained human resources in the health sector affects implementation of programmes. Improvement in nutrition, sanitation and education is essential to achieving MDGs 4 and 5. But recent estimates by UN organisations including WHO and UNICEF give reason for optimism. The estimated annual drop in MMR is 4.9% against the required rate of 5.5% and it is predicted that the MMR may reach 135 per 100 000 live births by 2015, a mere 26 points above the target of 109.

MDG 4 seems to be more difficult to achieve. At the present rate, by 2015 India’s IMR will be 46 compared with the target of 26.7 and the under-5 mortality will be 70 per 1000 compared with the target of 42. Considering the fact that 66% of IMR consists of neonatal deaths, the rational approach should be to focus on maternity and newborn services as a package. Increasing institutional deliveries is the key prerequisite. It is important to include the private healthcare providers as a major share of curative health care is provided by this sector. Recent experience in the states of Tamil Nadu (cash incentives dramatically increasing hospital deliveries) and Gujarat (Chiranjeevi project, in which direct payment to private healthcare providers increased deliveries in private facilities) are to be extended to other states.

To ease the financial burden on the family, governmental support is essential and this can be achieved by the government insisting on and participating in insurance coverage for pregnancy, child birth and newborn care. The Prime Minister of India made a statement on 18 March 2011 that India has to raise the public spending on health from the present level of less than 2% to 5%. This gives further hope that the MDGs will be achieved. The political will of the government is the most crucial requirement for achieving MDGs 4 and 5.

While preparing strategies it is essential to insist on minimum standards at health facilities; otherwise the trust of the lay person in modern health care cannot be sustained. It is essential to monitor the quality of care provided, for example by regular audit of care. Otherwise, unhealthy trends will become established (e.g. very high caesarean rates where modern medical care is provided). Auditing of maternal and perinatal deaths should be compulsory with the principles of confidential review (anonymous review on a ‘no name, no blame’ basis) maintained.

The statement of the permanent representative of India to the UN, Sri Hardeep Singh Puri, gives hope that India will achieve MDGs 4 and 5. He stated: ‘India will not only have met the goals but it will be a shining example for other countries’ (September 2010).

Disclosure of interests

No author or anyone in the acknowledgement list has any conflict of interest in preparing and presenting this article.

Funding

No funding has been accepted either by any author or by any one from the acknowledgement list.

Acknowledgements

We sincerely acknowledge the active guidance and support of Prof Shyam Desai, Dr P. Das Mahapatra, Dr Narendra Malhotra, Dr Sanjay Gupte, Dr Sohani Verma, Mr Samin Panda, FRCOG, Prof Chandrakant S. Pandav and Prof Dileep Mavalankar.