Poverty, education, and exposure to a community health worker are more important than age at marriage in determining whether a mother will be able to have a safe birth in a medical facility, according to a first-of-its-kind study on utilisation of institutional delivery in the country.
The research comes at a time the government has proposed to raise the age of marriage for women to 21 years in order to reduce maternal deaths — a decision that has come under heavy criticism for ignoring social realities such as poverty, education and access to health services that are said to play a bigger role in preventing child marriages.
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Published in the peer-reviewed journal Global Health Action , the study analyses data on State-level maternal mortality ratio (2016 to 2018), as well as the National Family Health Survey-4 (2015-2016). The study is unique in its exploration of socio-demographic factors as well as barriers in low coverage of institutional deliveries, which is a key intervention in averting the risk of maternal mortality due to childbirth-related complications. It has been authored by Ria Saha, a public health consultant in the U.K., and Pintu Paul, a Ph.D. candidate at the Jawaharlal Nehru University, New Delhi.
It focuses on nine low-performing States (LPS) with high burden of maternal mortality — Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand. These States constitute about half of the country’s population and contribute 62% of maternal deaths, 71% of infant deaths, 72% of under-five (years) deaths, and 61% of births in the country. They also account for 12% of global maternal deaths.
India has a maternal mortality rate of 113 per 100,000, and the rate remains “alarmingly high” in these nine States at 161 deaths per 100,000 .
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“As far as socio-demographic factors are concerned poverty (1.4 to 3.5) is responsible more than twice as much as age at marriage (.78) in determining whether a woman will seek institutional delivery. Education (1.2 to 3.8) is 1.5 times more important than age at marriage. Among other factors, interaction with a community health worker (1.63) and awareness campaigns (1.1 to 1.3) had a greater impact than age at marriage. However, distance to the health facility (.79) and age at marriage had almost similar influences on institutional deliveries,” Mr. Paul told The Hindu in an e-mail.
“The influence of educational attainment appeared to be strongest in Assam and Chhattisgarh, where women with a higher level of education were about five times more likely to deliver in a health facility than women who had no education. In Assam, women from the richest wealth index were almost 14 times more likely to deliver in a health institution than those from the poorest wealth index. Similarly, the odds of delivering in a health facility among the richest women were about five to six-fold higher in states likes Jharkhand, Madhya Pradesh, and Uttarakhand than the poorest women,” according to the study.
As far as barriers in accessing institutional deliveries were concerned, about 17% of women expressed distance or lack of transportation, and 16% cited costs, to be some of the challenges. Other reasons were facility closures (10%), poor service or trust issues (6%).
The authors recommend State-specific interventions not only to increase the number of public health facilities but also to improve associated quality of care, underlining that inadequate clinical training and insufficient skilled human resources affected the quality of available maternity services resulting in low coverage of institutional deliveries.
