Maternal Deaths and Recent Improvements in Institutional Delivery- worth

discussing

There has been some discussion recently on the availability of health data (especially
relating to maternity and mother’s deaths) and its interpretation. Most of the data is
open to public scrutiny- so it is possible to quickly clarify some basic issues for the lay
reader.

Institutional Deliveries
Institutional Births in West Bengal reported by NFHS 1992-93 were 32.0% and in
NFHS 1998-99 they were 40.1%
Institutional births reported by NFHS 2005-06 were 43.1% (looking at Deliveries in
2004).
(The above data is quoted from Health On The March 2008-09 official publication of
State Bureau of Health Intelligence)
DLHS 2003-04 shows 46.3% institutional deliveries. DLHS 2007-08 was 49.2%
(looking at Deliveries in 2006). The methodology of this survey is a bit different from
NFHS.

Two years later CES 2009 (looking at Deliveries in 2008) gives a figure of 70%
institutional births (in a sample of 838). 45 % deliveries were in Government facilities
alone and 25% in other health facilities.

The Indian average was even better at 72.9% institutional births.

(http://www.unicef.org/india/West_Bengal_Fact_Sheet.pdf)
The Coverage Evaluation Survey 2009 (CES-2009), was conducted during November
2009 to January 2010. The data for the CES 2009 was collected from mothers or care
takers of child aged 12-23 months for child care services and from women who
delivered during 12 months preceding the survey. Sample for each state was
estimated to give results at 5% margin of error and 95% confidence interval. It was
decided to have deep stratification that will make the samples more efficient and
sampling biases get reduced considerably. Further, more sample was covered from
bigger states. In each state, rural-urban sample was allocated in 60 to 40 ratios.
Number of women studied in CES West Bengal who delivered in previous 12 months 518 rural + 320 urban
=838 total
Number of Households studied in CES West Bengal 1007 rural + 642 urban =1649 total

Provided the NFHS and CES methodologies are comparable (and data reliable) this
suggests a large increase in deliveries in government institutions following the
implementation of JSY under NRHM.

The Health on the March 2008-09 also gives state government data on JSY and
institutional deliveries. There were 572,651 JSY beneficiaries in 2007-08 and 748,343
in 2008-09.
Institutional Deliveries increased from 205,761 in 2007-08 to 332,246 in 2008-09.
This seems to agree with the hypothesis.

Maternal Deaths

Health On the March 2008-09 gives the following data on maternal deaths. West
Bengal MMR in 2004-06 (from Registrar General GoI) was 141 (with 95% confidence
interval of 99 to 183: sample size 31204) as compared to 254 in India as a whole with
95% confidence interval of 239 to 269).
Maternal Death calculations require large samples. It is not worthwhile to do very
frequent studies on MMR or to do studies in very small populations, as variation is
very wide. This is seen in the very wide confidence intervals seen above. MMR
calculation is an exercise which shows trends over large populations or long periods
of time. This is a problem in using it for routine monitoring or to make annual health/
administrative plans. This is why Maternal Death Review is being introduced in many
districts of this state. This (Maternal Death Review) looks at individual deaths and
draws lessons for improving the care of pregnant mothers.

The Debate

I hope we can get more details of the doubts expressed recently. I believe some data
with community wise break downs was presented. This is good in itself. Studies were
done examining health data according to social class in Britain. Institutional
deliveries by class or community are easy to compare. A sample size of around 1000
for each group should be enough (see the CES sample size). However it may be
difficult to get repeat data on MMR (if the sample size for each class or community
needs to be 30,000 or more). So we could rather look at Maternal Death Review data
from districts with significant population of distinct groups (eg Murshidabad) to see if
there are points worth reflecting on and acting on. Medical colleges in West Bengal
are already involved in this valuable task.

Prabir