Innovations in Primary Healthcare: A Review of Initiatives to Promote Maternal Health in Tamil Nadu

Abstract

One of the key factors that has helped the state of Tamil Nadu to make significant progress in the health sector, especially in maternal health, is an enabling political environment in the state that has prioritised programmes for the welfare of women and children, irrespective of the party in power. This article reviews 10 key innovations in maternal health and tribal health introduced in the state of Tamil Nadu from 2005–2006 to 2020–2021. The specific questions addressed are as follows: what are the special innovative schemes introduced by the state of Tamil Nadu to promote maternal health? Whether and to what extent utilisation of public delivery system for maternal services has increased over the past 15 years or so?

The overall impact of these initiatives on the maternal health of the state is assessed by analysing two indicators: trends in maternal mortality ratio (MMR) and financial burden due to delivery in public and private facilities. MMR in the state of Tamil Nadu is steadily falling—from 111 in 2004–2006 to 60 in 2016–2018. While average out-of-pocket expenditure (OOPE) during delivery in the public sector has increased from ₹2,454 in 2014 to ₹3,465 in 2017–2018, in the private sector, it has increased from ₹32,182 in 2014 to ₹34,635 in 2017–2018. OOPE in private facilities is nearly ten times higher than OOPE in public facilities, in both rural and urban areas. While the overall status of maternal health has improved significantly in the state, there are wide variations within and across districts. However, significant improvements in the overall health status can be achieved only if such inequities are reduced systematically, and efforts are being made to reduce such inequities.

Keywords

Tamil Nadu maternal health maternal and child health maternal mortality pregnancy childbirth

Introduction

Tamil Nadu is known for its impressive achievements in the health sector. One of the key factors that has helped the state to make significant progress, especially in maternal health, has been an enabling political environment in the state, where the political system has prioritised programmes for the welfare of women and children, irrespective of the party in power. Combined with comparatively better social status for women in the state, this policy support has translated to higher female literacy, reduction in early marriages and teenage pregnancies, and increased awareness and adoption of family welfare practices, leading to a rapid fall in the population growth rate. A dynamic public health system has made use of this environment to progress towards its goal of making pregnancy safer through effective women-centred initiatives. A study on Tamil Nadu’s achievement of good health at low cost has further identified the state’s emphasis on primary health, creating a strong network of primary health centres (PHCs) and deploying well-trained female health workers at the health sub-centre level as one of the underlying conditions, which helped the state achieve its goals in the health sector (Balabanova et al., 2011). The robust drug distribution system in the state set up as early as 1995 and the ability of the state to finance health programmes by pooling together resources from state and central government have been other key factors in the state’s success. The state’s unique public health cadre, which helped manage its various initiatives for better maternal health as well as reaching the unreached, has played a key role in the design and implementation of various innovative programmes for service delivery (Padmanaban et al., 2009; WHO, 2009).

Objectives

This article presents a review of key innovations in maternal health and tribal health introduced in the state of Tamil Nadu from 2005–2006 to 2020–2021. The specific questions addressed are as follows: what are the innovative schemes introduced by the state of Tamil Nadu to promote maternal health? Whether and to what extent utilisation of public delivery system for maternal services has increased over the past 15 years or so?

The article is organised as follows: the third section presents the methodology adopted to address the aforementioned two specific questions that are posed. The fourth section presents key features of schemes that the Tamil Nadu government introduced to promote maternal health, including in tribal areas; The fifth section presents the analysis and results from National Sample Survey (NSS) data on the use of maternal health services and financial expenses incurred for birth delivery in public facilities over the years as an evidence of cumulative impact of the various schemes/services outlined in the fourth section. The article concludes with some remarks on challenges that the state continues to face in improving the maternal health further.

Methodology

The Policy Note of the Health and Family Welfare Department of Government of Tamil Nadu was reviewed from the year 2005–2006 to 2020–2021 (Government of Tamil Nadu, 2005–2006 to 2020–2021). A total of 10 specific maternal health schemes (including three schemes for tribal and remote areas) were identified, which were either introduced or strengthened during this period. These 10 schemes/initiatives were selected (from a long list of initiatives) based on innovativeness and criticality for improving maternal health (since they are more directly aimed at reducing maternal deaths and related delivery). Details of each of these schemes were collected and clarified with officials who had knowledge on these schemes to ensure a holistic and thorough understanding of the importance of these schemes and the way they have evolved over the years.

The pattern on the use of maternal and child health (MCH) services in Tami Nadu was analysed using the NSS database of 2005–2006 (60th round), 2014 (71st round) and 2017–2018 (75th round). Unit-level household data were analysed with respect to access and out-of-pocket expenditure (OOPE) for MCH services for the state as a whole.

Government Initiatives

Factors that Helped Tamil Nadu Achieve Significant Gains in Maternal Health

This section highlights the key features of the 10 special initiatives that the Tamil Nadu government has introduced to promote maternal health. As mentioned earlier, this section is based on careful review of policy notes of the Health and Family Welfare Department (Government of Tamil Nadu, 2005–2006 to 2020–2021) for the years from 2005 to 2021.

Some of these initiatives were introduced and have been implemented in the state before 2005 and have been strengthened during the past 15 years, whereas other initiatives came into force during this period. Some are large schemes that could impact the outcome indicators directly, while others are focused on specific vulnerable groups. Further, some of the schemes are common to all states, being funded under the National Health Mission (NHM) or other centrally sponsored schemes, but implemented in an innovative way in Tamil Nadu. There are schemes that are unique to the state being funded by the state government or are externally funded. Taken together, these initiatives have enabled the state to make rapid strides in achieving better maternal health.

Comprehensive Emergency Obstetric and Newborn Care

Comprehensive Emergency Obstetric and Newborn Care (CEmONC) is an essential intervention in the prevention of maternal and neonatal deaths. While Basic Emergency Obstetric and Newborn Care (BEmONC) is provided in almost all PHCs in the state, Tamil Nadu established a 24-hour CEmONC services in each district where defined emergency services are available for delivery and care of the neonates. Initially, two facilities per district were upgraded as CEmONC facilities through geographical mapping, the criterion being that no woman should travel more than 1 hour to reach a CEmONC facility. The identified facilities were upgraded on a priority basis with human resources, infrastructure and equipment. Currently, 22 medical college hospitals and 104 secondary care hospitals are providing these services round the clock.

The CEmONC centres have separate obstetric and paediatric casualty services in addition to general casualty services. Each has an operating theatre, a well-equipped laboratory and a blood bank. Every CEmONC centre is mandated to undergo a certification process to ensure maintenance of standards and quality of care. There is also a continuous monitoring and evaluation mechanism in place at various levels to assess the performance of these centres.

Dr Muthulakshmi Reddy Maternity Benefit Scheme

Malnutrition and undernutrition are major reasons for high maternal and perinatal morbidity and mortality since pregnant women, especially in underprivileged families, do not get the added requirement of calories during pregnancy and postnatal periods. The major cause for this inadequate intake is poor socio-economic status—mothers from these poorer sections continue to work as they are not able to afford loss of wages, and other day-to-day needs take precedence over nutritious food. The Dr Muthulakshmi Reddy Maternity Benefit Scheme was introduced by the state as early as 1989 to provide assistance to poor pregnant women/mothers to meet expenses for a nutritious diet, to compensate the loss of income during motherhood and to avoid low birth weight of newborn babies.

The assistance, which started at ₹200 per beneficiary, became a national programme in 1995. During the years that followed, the state has redesigned the scheme, introducing conditionalities for eligibility and increasing the beneficiary payment to its current level of ₹18,000. This is the highest conditional cash transfer scheme all over India. The amount increased from ₹200 to ₹300 in 1992, to ₹500 in 1998, to ₹1,000 in 2006, to ₹12,000 in 2011, to ₹18,000 per beneficiary in 2017. The assistance (of ₹18,000 per beneficiary) under this scheme is disbursed in cash (in five instalments for ₹14,000) and in-kind (in two instalments for ₹4,000) to poor pregnant women who satisfy the conditions listed in Table 1.

Table 1.

Payment Schedule Under MRMBS.

Benefit	Conditionalities	Cash/In-kind Value ₹
I	Antenatal registration on or before 12 weeks	2,000
In-Kind	First nutrition kit on completion of third month (kind benefit)	2,000
II	After 4 months subject to the conditions	2,000
In-Kind	Second nutrition kit (kind benefit)	2,000
III	After delivery	4,000
IV	After completion of third dose of OPV/Rota/Penta valent	4,000
V	After completion of measles rubella vaccination	2,000
Total		18,000

Source: Department of Public Health and Preventive Medicine (GoTN).

Over the years, as a result of the revised design, there has been a significant improvement in early registration, antenatal visits and immunisation for the babies.

Pregnancy Infant Cohort Monitoring and Evaluation, and Linkage with Civil Registration System

The Pregnancy Infant Cohort Monitoring and Evaluation (PICME) is a unique mother and child tracking system, which captures the details of all pregnant mothers from the early stages of pregnancy, up to the date of delivery as well as postnatal services. It also captures the details of the newborn as well as the immunisation services given to the child.

The state was a trendsetter in introducing this software in the year 2009. The village health nurse (VHN)/auxiliary nurse midwife (ANM) visits households once every fortnight, identifies the pregnant women at an early stage and takes steps to register the mother and render MCH services, including immunisation services to the mother and newborn. The MCH services for the mother and children is registered, monitored and evaluated through PICME software. In 2012, the PICME software was linked to Dr Muthulakshmi Reddy Maternity Benefit Scheme discussed earlier. Hence, the eligible pregnant woman had to be registered through the PICME software in order to receive the cash transfer in her bank account. The MCH services that were conditional to the cash transfer like antenatal care (ANC) and immunisation were also monitored through the software.

In August 2017, the state rolled out an improved version of the PICME software (PICME 2.0) with special features. The state has a robust civil registration system (CRS) with a birth registration of 99.4%, which is the highest among the states in India. However, there are a few pregnant women who were being missed out in the PICME registration. These ‘missing’ mothers are mostly migrants and underprivileged. There was also a practical problem of ‘visitor’ mothers in Tamil Nadu, as most of the pregnant women move to their parents’ house for delivery and are often not registered by the system. It is observed that maternal deaths and infant deaths often occur among these missed-out mothers. Hence, to track all mothers without any omission, the state took an innovative step to link the PICME 2.0 software with the CRS software, which is now fully functional and implemented throughout the state. It is now not possible for a birth to be registered unless the mother has been registered in the PICME software and given a unique reproductive and child health ID (RCH ID).

To simplify the registration of migrant and unregistered mothers, such mothers can register themselves through common service centre/Online/102 Help line Call Centre through a self-registration process, which is later verified by the VHN.

This linkage of CRS software with the PICME 2.0, has minimised the dropout of migrant mothers, ‘visitor’ mothers, unregistered mothers from underprivileged sections and those mothers who delivered at private health facilities.

Maternal Death Audit

To identify the reasons behind maternal deaths, the state was the first in the country to start a compulsory audit of all maternal deaths. Though the concept of maternal death audit was started as early as 1994, it became fully established in 2004, with the objective ‘that all maternal deaths should be audited both at the community and at the institutional level’. This surveillance system has been valuable in evolving timely interventions from primary healthcare to tertiary care and reducing maternal mortality. The programme mandates that each maternal death be reported to the MCH commissioner within 24 hours of occurrence, irrespective of place of death—public facility or private nursing home or during transit.

A community-based maternal review (verbal autopsy) is carried out within a few days of reporting by a team comprising the block medical officer, the concerned PHC medical officer, community health nurse and village health nurse (VHN). This exercise tries to identify any societal causes and contributors to the death.

Facility-based review of maternal deaths as the second part of the review of maternal death is carried out in the facility where the woman was treated and/or had died. In the facility-based review, the causes, treatment given and circumstances of deaths are investigated to see whether these deaths could have been avoided. This also addresses the quality of care in the facility.

The findings of these reviews are placed before the Medical Death Audit Committee on a monthly basis. Minutes of the committee meetings are placed before the district RCH committee chaired by the district collector. The family of the deceased woman is also invited to attend this review to present their side of the story. The final report is also sent to the state MCH commissioner. Apart from this, a special audit by the MCH commissioner has also been initiated in the state from 2013 onwards through videoconferencing every Thursday of the week.

It is important to highlight here the practice of near-miss case audit: ‘near-miss’ events are defined either as acute obstetric complications that immediately threaten the survival of a woman but do not result in her death by chance or because of the hospital care she received during pregnancy, labour or within 6 weeks after the termination of pregnancy or delivery. The state also conducts audit of such ‘near-miss’ events since they can provide insights into the steps to be taken to avoid such situations in the future.

Special Strategies to Tackle Key Issues Contributing to Maternal Death

Table 2 summarises certain specific strategies adopted by the state to reduce maternal deaths (and MMR). These interventions were adopted based on problem–cause analysis.

Table 2.

Intervention Strategies Adopted to Reduce Maternal Mortality and MMR.

S. No.	Problem Statement	Name of the Activity	Special Strategy/Intervention
1	7% of high-order Births (HOB) contributes to 24% of maternal deaths	Special intervention for 120 blocks with higher percentage of higher order births	Additional sterilisation camps, interval IUCD promotion and injectable contraceptive
2	9% of the total maternal deaths during the intrapartum period is sepsis related	Improved infection control in intrapartum period	‘One-delivery-one-kit’ is promoted in all health institutions, and periodic swab/fumigation of labour room and operation theatre is ensured. To prevent sepsis-related complications, during post-partum period, AMMA Baby Care Kit is provided for all postnatal mothers
3	Out of 25% of total maternal deaths in the antenatal period, 5% is contributed by sepsis, which is largely due to faulty abortions	Provision of manual vacuum aspiration (MVA) services up to community health centre (CHC) level involving PHC doctors Provision of medical method of abortion (MMA) drugs and injectable contraceptives up to CHC level Antara—an injectable contraceptive and new oral contraceptive pill named Chhaya are recently introduced. Strong legal action against unlicensed quacks	Strict monitoring and supervision for implementation of the above activities in the field level by joint director (JD-HS) and deputy directors (DD-HS)
4	Pregnancy-induced hypertension (PIH) deaths contribute to 21% of maternal death	PIH mortality free campaign	Standard protocols to identify and treat hypertension during pregnancy through injection—magnesium sulphate adopted at PHC level itself. calcium tablet 500 mg twice daily is provided to prevent pregnancy-induced hypertension Special PIH screening and treatment campaign has been initiated from 15 August 2018 all over Tamil Nadu to increase awareness among the public, and early diagnosis and management of PIH
5	Deaths due to post-partum haemorrhage (PPH) account for nearly 20% of maternal deaths	Availability of Non-pneumatic anti-shock garments and misoprostol tablet are ensured even at the PHC level to avoid death due to post-partum haemorrhage.	Availability of safe blood maintained at all CEMoNC and blood storage centres

Sources: Government of Tamil Nadu (2005–2006 to 2020–2021).

High-risk Mother Observation

One of the important interventions for reducing maternal morbidity and deaths and improving maternal health has been the scheme for the identification and observation of high-risk mothers following a mentoring approach. Three types of mentoring have been initiated:

Virtual mentoring: Obstetricians from sub-district hospitals/district headquarter hospitals/government medical college hospitals have been pooled and allotted blocks based on the geographic contiguity of the respective institutions where they work. The obstetrician mentors the doctors through a ‘WhatsApp’ group.

Real mentoring: The mentor obstetrician guides the block team—block medical officer (MO)/PHC MO/upgraded community health centres (CHC)/urban community health centres (UCHC), on a one-to-one basis during emergencies.

Mentoring of secondary care institution by the tertiary care obstetrician: Antenatal mothers with high-risk factors are being admitted in the upgraded PHCs and are referred to appropriate CEmONC centres well before the expected date of delivery (EDD) to provide quality EmONC services and to prevent adverse outcomes. These secondary care institutions provide the backbone of services for complicated cases and, therefore, need monitoring by the tertiary care obstetricians, who guide and mentor the cases as well as ensure referral to the higher institutions whenever found necessary.

Emergency Referral Transport

One of the key learnings from the maternal death audit was that there is a delay in transport, especially for inter-facility referral. The 108 Ambulance Services are being operated on 24x7 basis, free of cost to the public through a single toll-free number since 2011–2012. Transport is free for pregnant women under this programme. Besides, Tamil Nadu has introduced a special vehicle for providing emergency transport in hilly areas and difficult terrains to address transport issues in these remote areas. Tamil Nadu also decided that the same system would be used to provide inter-facility transport, which was earlier carried out using ambulances belonging to the facilities, which was not very effective or timely (Joe et al., 2015). In the Tamil Nadu’s referral system, women, when in need of a referral, are provided ‘accompanied transfer’—that is, a healthcare provider accompanies the woman to the higher level facility, providing continuity in care during the time of transfer, and handing over the woman to a responsible provider at the higher level centre. In addition to this, communication is established through phone calls made to the higher facility to ensure care on arrival.

Birth Companion Programme

Based on the experience of Christian Medical College (CMC), Vellore, with Birth Companion Program in 2002, and in Chennai Municipal Corporation, this programme was scaled up across all government hospitals in the state in 2004. This was a pioneering and most innovative programme introduced by any state until then, and the Government of India adopted this programme almost 10 years later. A person can be a companion if she is a female relative of the pregnant woman and if she has undergone labour earlier and would accompany the mother during the labour period. As noted in the Policy Note of 2019–2020, this programme has had a positive impact on increasing institutional deliveries in public facilities. Another related scheme introduced around the same period is the Maternity Picnic and Bangle Ceremony: this helps to build more trust and confidence in availing services from public institutions. It is organised by the VHNs and ANMs under the guidance of the medical officer.

Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy Clinics Integrated with Regular System

Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy (AYUSH) clinics, in particular Siddha clinics, have been established in PHCs over the years across the state. All the block-level PHCs have a Siddha unit, and all district hospitals provide other AYUSH services. As per Policy Note 2019–2020, the state has a total of 1,875 AYUSH clinics located in public institutions. Of these, close to 900 Siddha clinics are located in PHCs, half of which are supported by the NHM. About 70 AYUSH wellness clinics provide yoga and naturopathy services for expectant mothers. Expectant mothers visiting PHCs for ANC are categorised as per trimester and are given consultation by yoga and naturopathy physicians. The state government has also launched the Amma Magaperu Sanjeevi Scheme in 2016, where pregnant women are provided with a kit containing 11 Siddha medicines beneficial for both mother and baby.

Schemes Introduced in Tribal Areas

Prevention and control of sickle cell anaemia and thalassemia

Thalassemia and sickle cell anaemia are common among the tribal population. The state was among the first to introduce a programme in 2017 for early detection of these defects and to provide genetic counselling with a view to prevent transmission of the carrier from parents to offspring. The programme is being implemented in 30 tribal blocks (from 13 districts), including children of 12th standard, and unmarried dropouts from schools. Five regional centres have been established for providing ‘comprehensive integrated treatment’ for those suffering from sickle cell anaemia and Thalassemia. The state has also established integrated treatment centres for these conditions in five medical colleges.

Birth waiting room in tribal regions

To overcome geographical barriers to access PHCs in tribal regions, birth waiting rooms (BWRs) were established in 2014 in 17 PHCs, located in remote hilly regions of 16 districts. These BWRs admit tribal pregnant women 2 weeks before the EDD to provide safe institutional delivery. BWRs are manned by a medical officer, staff nurses and supportive staff to provide continuous monitoring of vitals. They also provide nutritious diet for the mother and one attendant throughout their stay. This scheme has helped to reduce home deliveries as well as maternal and perinatal morbidity and mortality caused by delays in reaching obstetric care. During the year 2018–2019, 2,851 mothers have used BWRs.

Tribal counsellors

Tribal counsellors have been placed in 10 government hospitals in tribal districts. They act as ambassadors between the health systems and tribal community. They also function as health activists in institutions where they not only create awareness on health and its determinants but also motivate the community towards healthy living practices.

Hospital on wheels programme

Hospital on Wheels Programme in rural areas have been provided in all blocks of the state so as to cover remote, hilly/tribal and inaccessible areas. There are 395 hospitals on wheels, each manned by one medical officer, one nurse, one lab technician, one driver and one attendant. Each mobile medical unit covers 42 villages on an average based on fixed days as per a fixed tour programme.

Assessing the impact of each of these initiatives and cumulative effects of these schemes over the years is not an easy task, given the fact that there are also several ‘social, economic and environmental’ factors that have an impact on maternal health. However, presented here is the trend in the use of public facilities for maternity services over the years (from 1995 to 2018), which are known as ‘process indicators’ as an evidence of the cumulative effects of several initiatives and schemes to improve maternal health of the state.

Utilisation of Maternal Health Services: Evidence from National Sample Surveys

Utilisation of public facilities for birth delivery among the poorest income quintiles has generally increased over a longer period of time (1995-2018) as reflected through the 52nd (1995–1996), 60th (2004), 71st (2014), 75th (2017-18) NSS surveys. However, the proportion of those in the poorest quintile using public facilities fell, while those of the higher quintiles increased, although overall utilisation of the public facilities remains pro-poor (Figure 1).

Figure 1.

Source: Authors’ calculations based on unit records NSSO (52nd, 60th, 71st and 75th rounds).

Institutional Delivery

The proportion of institutional delivery in Tamil Nadu has almost reached 100% in 2017–2018, whereas it was 95.4% in 2014. The share of the public sector in institutional deliveries has increased from 56.3% (2014) to 62.7% (2017–2018). This increase mainly comes from the public hospitals, which increased from 49.6% to 58.3%. The share of HSC/PHC/CHC fell marginally from 6.82% in 2014 to 4.41% in 2017–2018. Decline in home-based deliveries during this period is significant (Table 3).

Table 3.

Percentage Distribution of Women aged 15–49 by Place of Childbirth During the Past 365 days in Tamil Nadu.

	71st (2014)			75th (2017–2018)
Place of Delivery	Rural	Urban	Total	Rural	Urban	Total
HSC/PHC/CHC	9.55	3.6	6.82	6.67	1.63	4.41
Public hospitals	54.03	44.28	49.55	69.01	45.18	58.33
Private hospitals	30.69	49.02	39.11	24.32	53.15	37.24
Home	5.74	3.1	4.53	0	0.04	0.02

Source: Authors’ calculations based on unit records of NSSO (71st and 75th rounds).

The trend in the use of antenatal and postnatal services was also analysed as an evidence of cumulative effects of effective implementation of maternal services in the state—though the trends are shown only for the period from 2014 to 2018.

Prenatal and Postnatal Care

In 2017–2018, 97.9% of the pregnant women received ANC as compared to 99.6% in 2014. However, the proportion of women receiving postnatal care increased from 88.6% (in 2014) to 97.8% (in 2017–2018). Rural areas of Tamil Nadu witnessed a significant increase in postnatal care from 85.6% (in 2014) to 97.6% (2017–2018, refer Table 4).

Table 4.

Proportion of Women Receiving Prenatal and Postnatal Care in Tamil Nadu (in %).

	71st (2014)			75th (2017–2018)
	Rural	Urban	Total	Rural	Urban	Total
Proportion of pregnant women receiving all prenatal care	99.3	99.9	99.6	98.3	97.5	97.9
Proportion of pregnant women receiving postnatal care	85.6	92.1	88.6	97.9	97.6	97.8

Source: Authors’ calculations based on unit records of NSSO (71st and 75th rounds).

The share of public facilities during prenatal care increased from 56.1% (2014) to 67.7% (2018–2019), and during postnatal care, it increased from 55.7% to 64.1%. There is a significant increase in the use of public facilities in rural and urban areas, but the proportional increase was significantly higher in rural areas than in urban areas of Tamil Nadu (Table 5).

Table 5.

Percentage Share of the Public and Private Sector in Total Pre- and Postnatal Care in Tamil Nadu.

		71st (2014)			75th (2017–2018)
		Rural	Urban	Total	Rural	Urban	Total
Prenatal	Public	66.2	45.1	56.1	79.7	54.1	67.7
	Private	33.8	54.9	43.9	20.3	45.9	32.3
	Total	100.0	100.	100.0	100.0	100.0	100.0
Postnatal	Public	64.6	46.1	55.7	77.3	47.8	64.1
	Private	35.4	53.9	44.3	22.7	52.2	35.9
	Total	100	100	100	100.0	100	100

Source: Authors’ calculations based on unit records of NSSO (71st and 75th rounds).

Childbirth

In terms of outcome of total pregnancy, there was a significant increase in live births from 72.8% (2014) to 88.8% (2017–2018). During the same period, there was a reduction in abortion from 7.3% (71st round) to 2.5% (75th round, refer Table 6). There is also a significant increase in live births in rural areas, where it increased from 73.5% in 2014 to 91.8% in 2017–2018.

Table 6.

Outcome of Pregnancy in Tamil Nadu (in %).

	71st (2014)			75th (2017–2018)
	Rural	Urban	Total	Rural	Urban	Total
Live birth	73.5	72.1	72.8	91.8	85.5	88.9
Still birth	0.5	1.5	0.9	0.2	0.1	0.1
Abortion	10	4	7.3	2.9	2.1	2.5
Pregnancy continuing	15.9	21.8	18.8	5.0	12.3	8.4
Others	0	0.3	0.2	0.1	0	0.1
Total	100	100	100	100	100	100

Source: Authors’ calculations based on unit records of NSSO (71st and 75th rounds).

Discussion

In order to assess the overall impact of these and other initiatives taken together on the maternal health of the state, the review used two indicators: (a) trends in maternal mortality ratio and (b) financial burden due to delivery in public and private facilities.

Maternal Mortality Ratio in Tamil Nadu Versus India

As Figure 2 shows, the fall in MMR since 2004–2006 has been steady—from 111 in 2004–2006 to 60 in 2016–2018. There is always an unanswered question: whether and to what extent the innovative initiatives by the government towards improving maternal and child health could have been more effective in lowering the MMR further over the years.

Figure 2.

Source: RGI (2018).

Expenditure Towards Institutional Care and Childbirth

Average (OOPE) during delivery in the public sector increased from ₹2,454 in 2014 to ₹3,465 in 2017–2018. On the other hand, in the private sector, it increased from ₹32,182 in 2014 to ₹34,635 in 2017–2018. In the public sector, average OOPE for a normal delivery was ₹2,927, whereas, in the private sector, it was nine times higher, at ₹26,032. For C-section delivery, average OOPE in public institutions was ₹4,514 against ₹42,779 in the private sector (Table 7).

Table 7.

OOPE in Public and Private Sector During Delivery in Tamil Nadu in 2014 and 2017–2018 (in ₹).

		71st (2014)			75th (2017–2018)
		Rural	Urban	Total	Rural	Urban	Total
Public	Normal				2,902	2,979	2.927
	C-section				4,366	4.769	4,514
	All	2,214	2,776	2,454	3,374	3,548	3,465
Private	Normal				23,882	26,963	26,032
	C-section				43,632	42,196	42,779
	All	31,811	32,448	32,182	35,469	34,175	34,635

Source: Authors’ calculations based on unit records of NSSO (71st and 75th rounds).

OOPE for delivery in public facilities for childbirth was ₹3,548 in urban areas, whereas it was ₹3,374 for rural areas. Under the private sector, OOPE was ₹35,469 in rural areas and ₹34,175 in urban areas.

What is important to note here is that the average expenditure for delivery in private facilities is about 9–10 times more than that in public facilities, in rural and urban areas.

While the overall status of maternal health has improved significantly in the state, there are wide variations within and across districts. All districts have blocks that suffer from lack of basic health infrastructure. While efforts are being made to reduce such inequities, significant improvements in the overall health status can be addressed only if such inequities are reduced systematically as the primary objective of public health policy of the state (Muraleedharan & Dash, 2017).

Over-medicalisation, as shown by the high percentage of cesarean deliveries, continues to be a concern. Malnutrition, especially iron deficiency anaemia among pregnant women, poses a serious challenge for policymakers. The state will have to continue to enhance and sustain its efforts to improve maternal health by constantly monitoring the existing programmes, while at the same time reviewing their design to ensure that the services given to pregnant women are accessible, affordable and of the highest quality.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was funded by a grant from the Bill and Melinda Gates Foundation to the ACCESS Health International, Inc. (Grant number: INV-007165).

References

Balabanova

, McKee

, & Mills (Eds.). (2011). ‘Good Health at Low Cost’ 25 years on—What makes a successful health system? LSHTM.

Government of Tamil Nadu. (2005–2006 to 2020–2021). Policy note of Health and Family Welfare Department . Government of Tamil Nadu.

Joe

, Subha Sri

, Sharma

, et al. (2015). Strategies for safe motherhood in Tamil Nadu: A note (Working Papers ID7585), eSocialSciences.

Muraleedharan

V. R.

, & Dash

(2017). Chapter 6: Gender. Tamil Nadu State Human Development Report . State Planning Commission, Government of Tamil Nadu. http://www.spc.tn.gov.in/TNHDR2017/salientfeatures_SHDR_2017.pdf

Padmanaban

, Raman

P. S.

, & Mavalankar

D. V.

(2009). Innovations and challenges in reducing maternal mortality in Tamil Nadu, India. Journal of Health Population & Nutrition , 27(2), 202–219.

Registrar-General of India (RGI). (2018). Sample registration system . Government of India.

World Health Organization (WHO). (2009). Safer pregnancy in Tamil Nadu: From vision to reality . WHO.