Maternal mortality rate from park textbook
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Maternal Mortality - Park's Textbook of Preventive and Social Medicine
(Park's Textbook of Preventive and Social Medicine, Chapter on Maternal and Child Health)
Key Definitions
Maternal Death: Death of a woman while pregnant or within 42 days of termination of pregnancy (regardless of duration/site), from causes related to or aggravated by the pregnancy or its management (not from accidental or incidental causes).
Four Important Indicators
| Indicator | Definition |
|---|---|
| Maternal Mortality Ratio (MMR) | Number of maternal deaths per 100,000 live births during the same period - measures risk per delivery |
| Maternal Mortality Rate (MMRate) | Number of maternal deaths divided by person-years lived by women of reproductive age (15-49 years) - captures both risk per pregnancy AND fertility level |
| Adult Lifetime Risk | Probability that a 15-year-old girl will eventually die from a maternal cause |
| Proportion of Maternal Deaths (PM) | Maternal deaths / total deaths among women aged 15-49 years |
Note: MMR and MMRate are often confused. The ratio (per live births) is the more commonly quoted public health indicator.
Global MMR (2017 WHO Estimates)
- 295,000 maternal deaths globally in 2017
- Global MMR = 211 per 100,000 live births (95% UI: 199-243)
- Global lifetime risk = 1 in 190
| Category | MMR |
|---|---|
| Global average | 211 |
| Least developed countries | 415 |
| Sub-Saharan Africa | 542 (very high) |
| South Sudan | 1,150 (extremely high) |
| Chad | 1,140 |
| Sierra Leone | 1,120 |
| South Asia (2017) | 157 (down from 384 in 2000 - 59% reduction) |
MMR classification:
- High: 300-499
- Very high: 500-999
- Extremely high: ≥ 1000
India - MMR (SRS RHIME Data, 2016-2018, Table 14)
India's MMR declined from 167 per lakh (100,000) live births in 2011-13 to 113 per lakh live births in 2016-18.
| State/Region | MMR | Maternal Mortality Rate | Lifetime Risk |
|---|---|---|---|
| India Total | 113 | 7.3 | 0.5% |
| EAG + Assam Subtotal | 161 | 13.2 | 0.5% |
| Assam | 215 | 14.0 | 0.5% |
| Uttar Pradesh | 197 | 17.8 | 0.6% |
| Madhya Pradesh | 173 | 15.9 | 0.6% |
| Rajasthan | 164 | 14.5 | 0.5% |
| Chhattisgarh | 159 | 12.1 | 0.4% |
| Odisha | 150 | 9.7 | 0.3% |
| Bihar | 149 | 15.1 | 0.5% |
| Jharkhand | 71 | 5.6 | 0.2% |
| Uttarakhand | 99 | 6.4 | 0.2% |
| South Subtotal | 67 | 3.6 | 0.1% |
| Kerala | 43 | 2.1 | 0.1% (best) |
| Tamil Nadu | 60 | 3.2 | 0.1% |
| Andhra Pradesh | 65 | 3.6 | 0.1% |
| Telangana | 63 | 3.6 | 0.1% |
| Karnataka | 92 | 4.9 | 0.2% |
| Other States Subtotal | 85 | -- | 0.2% |
| Maharashtra | 46 | 2.6 | 0.1% |
| Gujarat | 75 | 5.1 | 0.2% |
| Punjab | 129 | 7.0 | 0.2% |
| West Bengal | 98 | 5.0 | 0.2% |
| Haryana | 91 | 7.0 | 0.2% |
States achieving MMR < 100 (SDG target): Kerala (43), Maharashtra (46), Tamil Nadu (60), Andhra Pradesh (65), Telangana (63), Gujarat (75).
Causes of Maternal Deaths in India
Obstetric (Direct) Causes:
- Haemorrhage (leading cause)
- Sepsis
- Unsafe abortion
- Obstructed labour
- Hypertensive disorders (toxaemias)
Non-Obstetric (Indirect) Causes:
- Anaemia
- Cardiac, renal, hepatic, metabolic diseases
- Infectious diseases
- Malignancy
Determinants of Maternal Mortality
| Medical Causes | Social Factors |
|---|---|
| Haemorrhage, infection, obstructed labour, unsafe abortion, toxaemias | Early age at childbirth, high parity, closely spaced pregnancies, malnutrition, poverty |
| Anaemia, associated diseases (cardiac, renal, hepatic) | Illiteracy, delivery by untrained dais, poor transport, social customs |
National/International Targets
- SDG 3.1: Reduce global MMR to < 70 per 100,000 live births by 2030
- National Population Policy 2000: Reduce MMR to < 100 per lakh live births
- India's SDG 3.1.1 value: 113 (2016-18) vs Global: 211
Key Takeaways for Exams
- MMR = maternal deaths per 100,000 live births (ratio, not rate)
- MMRate = deaths per person-years of women aged 15-49
- India's MMR (2016-18) = 113 per lakh live births
- Highest MMR in India: Assam (215), Lowest: Kerala (43)
- ~44,000 mothers die annually in India
- About 50-70% of maternal deaths occur in the postpartum period; 45% within the first 24 hours after delivery
- Global MMR (2017) = 211; Sub-Saharan Africa highest at 542
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Infant Mortality Rate (IMR) - Park's Textbook of Preventive and Social Medicine
Definition
Infant Mortality Rate (IMR) is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year, usually expressed as a rate per 1,000 live births.
IMR is one of the most universally accepted indicators of health status - not only of infants, but of the whole population and the socio-economic conditions under which they live. It is also a sensitive indicator of the availability, utilization and effectiveness of health care, particularly perinatal care.
Components of IMR
IMR is divided into two parts:
| Component | Period | Key Causes |
|---|---|---|
| Neonatal Mortality Rate | 0-28 days (4 weeks) | Endogenous/biological factors |
| Post-neonatal Mortality Rate | 1-12 months | Exogenous/environmental factors |
- Early Neonatal: 0-7 days
- Late Neonatal: 7-28 days
Formula:
- NMR = Deaths under 28 days / Total live births × 1000
- Post-NMR = IMR - NMR
India - Historical Trend in IMR (SRS Data)
| Period / Year | IMR (per 1000 live births) |
|---|---|
| 1911-15 | 204 |
| 1970 | 129 |
| 1980 | 114 |
| 2018 | 32 |
Despite this significant decline, India's rates remain high compared to developed countries (which are mostly 3-7 per 1000 live births).
- Rural IMR (2018): 36
- Urban IMR (2018): 23
State-wise IMR in India (2018) - Table 24
| State/UT | Total | Rural | Urban |
|---|---|---|---|
| Madhya Pradesh | 48 (highest) | 52 | 38 |
| Odisha | 40 | 43 | 22 |
| Assam | 41 | 44 | 20 |
| Chhattisgarh | 41 | 42 | 35 |
| Uttar Pradesh | 43 | 46 | 30 |
| Bihar | 32 | 32 | 30 |
| India Total | 32 | 36 | 23 |
| Haryana | 30 | 33 | 25 |
| Jharkhand | 30 | 31 | 26 |
| Andhra Pradesh | 29 | 33 | 21 |
| Gujarat | 28 | 33 | 20 |
| Karnataka | 23 | 25 | 20 |
| Himachal Pradesh | 19 | 20 | 14 |
| Tamil Nadu | 18 | 21 | 14 |
| Maharashtra | 17 | 20 | 12 |
| Punjab | 22 | 25 | 16 |
| West Bengal | 22 | 25 | 14 |
| Delhi | 13 | 8 | 13 |
| Kerala | 7 (lowest) | 9 | 5 |
Critical "infant mortality belt": Odisha, Madhya Pradesh, Assam, Bihar, Chhattisgarh, Uttar Pradesh, Rajasthan - all above national average.
Neonatal Mortality Rate (NMR) - India 2018
- India NMR (2018): ~23 per 1000 live births (neonatal deaths account for ~70% of infant deaths)
- Global NMR (2018): 18 per 1000 live births
- SDG target: Reduce NMR to ≤12 per 1000 live births in every country by 2030
Post-Neonatal Mortality Rate - India 2018
- India Post-NMR (2018): ~9 per 1000 live births
- Highest in: Assam (20), Odisha, Madhya Pradesh
- Lowest in: Kerala (2)
Causes of Infant Mortality (Table 26)
Neonatal Mortality (0-4 weeks) - Endogenous
- Low birth weight and prematurity (most important)
- Birth injury and difficult labour
- Sepsis
- Congenital anomalies
- Haemolytic disease of newborn
- Conditions of placenta and cord
- Diarrhoeal diseases
- Acute respiratory infections
- Tetanus
Post-neonatal Mortality (1-12 months) - Exogenous
- Diarrhoeal diseases
- Acute respiratory infections
- Other communicable diseases
- Malnutrition
- Congenital anomalies
- Accidents
Principal causes in India:
- Low birth weight: 57%
- Respiratory infections: 17%
- Congenital malformations: 5%
- Diarrhoeal diseases: 4%
- Birth injury: 3%
- Cord infection: 2%
- Unclassified: 18%
Factors Affecting IMR
Biological Factors:
- Birth weight (most important determinant)
- Age of mother (highest risk < 20 and > 35 years)
- Birth order / parity
- Sex of child (female IMR higher in India due to neglect)
- Multiple births
Socio-economic Factors:
- Poverty and low income
- Maternal illiteracy
- Poor housing and environmental sanitation
Healthcare Factors:
- Lack of antenatal care
- Untrained birth attendants
- Inadequate immunization coverage
- Poor nutrition / malnutrition
- Poor family planning (short birth intervals)
Decline in IMR - Contributing Factors
- Improved obstetric and perinatal care
- Better control of communicable diseases (immunization, ORS)
- Advances in chemotherapy and antibiotics
- Better nutrition - emphasis on breastfeeding
- Family planning - birth spacing
In developed countries, the dominant factor was socio-economic progress. In developing countries, medical services (mass disease control, immunization, antibiotics) made the major impact.
Key Targets
| Policy | IMR Target |
|---|---|
| SDG 3.2 | ≤ 12 NMR and ≤ 25 U5MR per 1000 live births by 2030 |
| National Population Policy 2000 | IMR < 30 per 1000 live births |
| India's current IMR (2018) | 32 |
Exam High-Yield Points
- IMR = deaths under 1 year per 1000 live births
- India's IMR (2018) = 32 (SRS data)
- Highest state: Madhya Pradesh (48), Lowest: Kerala (7)
- IMR = best single indicator of overall health status of a community
- Neonatal deaths = ~70% of infant deaths in India
- Leading cause of infant death in India = Low birth weight (57%)
- Neonatal mortality reflects endogenous factors; post-neonatal reflects exogenous factors
- IMR in developed countries = 3-7 per 1000 live births
- Perinatal mortality rate (India, 2018) = ~73 per 1000 live births + stillbirths (rural 26, urban 16)
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