By adopting certain strategies and addressing the multidimensional challenges in urban areas, India can reduce MMR and develop equitable maternal healthcare in cities
The UN-Habitat’s New Urban Agenda emphasises inclusive healthcare for developing smart cities, with a low maternal mortality ratio (MMR) being essential. MMR, the number of maternal deaths per 100,000 live births, reflects women's empowerment and is crucial for urban development aligned with Sustainable Development Goals (SDGs). Specifically, SDGs 3, 5, 10, and 11 focus on good health, gender equality, reduced inequalities, and inclusive cities. Additionally, SDG 3.1 aims to reduce MMR to below 70 by 2030.
Studies show that higher-income countries have lower MMRs than those in the Global South. In 2020, Germany, Australia, and Sweden recorded 34, 9, and 5 maternal deaths, respectively, while India had 23,753. Despite a 73 percent reduction in MMR from 2000-2020, India's MMR of 103 remains alarming, especially for disadvantaged groups in cities.
The urban poor, particularly those in informal settlements, face overcrowding, unstable housing, and low incomes.
Although cities offer better living conditions for reducing MMR, intra-urban inequalities are jarring. The urban poor, particularly those in informal settlements, face overcrowding, unstable housing, and low incomes. For example, Nairobi's urban poor have an MMR of 706 compared to the national average of 362. Similar challenges exist across the Global South, where basic necessities often overshadow health and safety. What challenges do cities face in reducing MMR? How can existing urban frameworks help address MMR? How can Indian cities effectively implement policies to lower MMR?
Among urban citizens, residents of informal settlements face a higher MMR due to many factors. For instance, access to hospitals in urban areas does not always translate to equal healthcare for all. Further, disadvantaged groups become more vulnerable due to delays in successive points of care. Moreover, maternal health and survival depend on living conditions and access to quality care, which are intrinsically tied to the place of residence. This is evident in informal urban settlements of Western India, where 49 percent of mothers do not receive the recommended amount of maternal care. Mothers may be forced to deliver at home due to the inability to travel to the hospital alone, administrative issues, or poor treatment by hospital staff.
Social norms often dictate maternal health care. The empowerment of women to make their own health choices is positively associated with increased use of maternal care. Gender discrimination is an issue in informal settlements and healthcare, potentially leading to poor quality care and discouraging women from using available public health facilities. A lack of autonomy can even impact a mother’s diet, with nutrients, such as iodine and calcium deficiency, commonly found in women across the Global South. For instance, 57 percent of mothers in Amritsar’s informal pockets consume less than the required number of Iron-Folic Acid tablets during pregnancy.
Gender discrimination is an issue in informal settlements and healthcare, potentially leading to poor quality care and discouraging women from using available public health facilities.
Erratic working hours, socio-economic exclusion, and unsteady settlement patterns make it even more difficult to reach out to disadvantaged groups in the city. These uncertainties lead to susceptible populations relying on more accessible unlicensed providers for health and maternal care. The residents of informal settlements are not necessarily homogenous, varying across parameters such as place of origin, socio-economic status, and length of residence. This heterogeneity makes a one-size-fits-all approach ineffective. The challenge of creating policy is often exacerbated by huge gaps in disaggregated data on residents of informal settlements, let alone gendered statistics.
In examining various global approaches to improving maternal health care, several toolkits have been developed to address the needs of different stakeholders. For instance, WHO’s toolkit addresses policymakers, healthcare managers, and non-governmental organisations. It includes worksheets, baseline assessment tools, and implementation strategies to overcome barriers to providing maternal health care. Mauritius’ toolkit targets mothers, explaining perinatal care and their child’s growth. India’s Ministry of Health and Family Welfare’s toolkit addresses healthcare workers and guides them through the design, protocol, and benchmarks for maternal health care.
Examining successful strategies from various countries can provide valuable insights into reducing MMRs. The MANOSHI project in Bangladesh uses community health workers for door-to-door perinatal checkups. At the same time, Maldives saw a 90 percent decrease in MMR from 1990-2015 by introducing a review process for maternal deaths to create preventative policies. In Rotterdam, non-medical risks like poverty were addressed by providing long-term secure housing to perinatal postpartum women. Implementing such policies in India is challenging due to its larger population, but targeting non-medical risks could reduce MMR in urban areas.
A successful multi-sectoral approach in Kampala improved referral facilities, increased ambulance purchases, and focused on human-centred design.
Further, Uganda aimed to reduce its MMR by 75 percent between 2000-2015 but achieved only a 30 percent reduction due to disjointed policy design despite implementing 14 policies. A successful multi-sectoral approach in Kampala improved referral facilities, increased ambulance purchases, and focused on human-centred design. India's urban healthcare is strained by rural populations seeking care at larger hospitals known for comprehensive services. Adopting Kampala's approach in India could alleviate pressure on public hospitals. Considering these global urban frameworks, Indian cities can enhance policy implementation for maternal healthcare.
India’s substantial progress in reducing MMR is due to policies like Janani Suraksha Yojana, Janani Shishu Suraksha Karayakaram, and Pradhan Mantri Surakshit Matritva Abhiyan, which provide financial assistance for institutional births and perinatal care. For instance, in Mumbai’s informal settlements, 94 percent of mothers make over three prenatal visits, and over 85 percent have institutional deliveries. In Kolkata’s informal settlements, 99 percent of mothers had institutional deliveries. However, implementation issues persist. MMR has plateaued in cities like Chandigarh at 100-120 despite increased institutional deliveries. Take the case of informal settlements in Jaipur, Jodhpur, Ajmer and Kota, where only 51 percent of mothers from susceptible groups opted for institutional deliveries due to prolonged wait times or distance from facilities. Further, a lack of knowledge about policies can cause unnecessary out-of-pocket expenses. Additionally, poor antenatal care quality leads to underutilisation of reproductive services.
India can further reduce its MMR by promoting community integration, enhancing health education, and encouraging collaborations with researchers and NGOs to identify inequities. For instance, Accredited Social Health Activists (ASHA) can use guidelines from the MANOSHI programme, such as building referral systems and or setting up help desks in facilities. A feedback system and regular quality checks can help monitor long-term impacts. Furthermore, sensitising administrative and hospital staff is essential for equipping them to implement initiatives effectively.
Black women in the United Kingdom are 3.7 times more likely to die after pregnancy than white women.
Furthermore, maternal mortality affects people disproportionately. For instance, Black women in the United Kingdom are 3.7 times more likely to die after pregnancy than white women. Addressing discrimination in maternal healthcare will involve correcting biased algorithms and making health workers aware of fair assessment and redressal mechanisms. This will involve having comprehensive and disaggregated data to identify disparities and evaluate the effectiveness of interventions. Moreover, gender discrimination, that significantly impacts MMR, can be addressed by creating more affordable healthcare and including men in MMR schemes.
Additionally, poor maternal mental health is widespread, with a 22 percent peripartum depression rate in India. Integrating maternal mental health into the National Mental Health Policy, and following initiatives like the Massachusetts Child Psychiatry Access Program for Moms, can help address this. These measures should be accompanied with a shift in attitude by prioritising the needs and aspirations of women in cities.
Finally, access to technology in low-resource settings is challenging, furthered by the gender digital divide. India can bridge this gap through policies like Digital Public Infrastructure, the Ayushman Bharat Digital Mission, and the National Digital Health Mission. E-health technology can be made accessible by coordination across government, hospitals, and health-tech companies. SMS technology, mobile health apps, and cell phones all offer affordable, effective alternatives for monitoring pregnant women, increasing health awareness, and improving care quality in informal settlements.
By applying these strategies and addressing the multidimensional challenges in urban areas, India can continue to make significant strides in reducing MMR and developing equitable maternal healthcare in cities.
Anusha Kesarkar-Gavankar is a Senior Fellow at the Observer Research Foundation
Gayatri Mehra is a Research Intern at the Observer Research Foundation
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Gayatri Mehra is a Research Intern at the Observer Research Foundation ...
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