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The UN-Habitat’s New Urban Agenda emphasises inclusive healthcare for developing smart cities, with a low maternal mortality rate (MMR) being essential.

Maternal Mortality in Urban Development

Low Maternal Mortality Rate (MMR) in Cities

The UN-Habitat’s New Urban Agenda emphasises the need for inclusive healthcare in the development of smart cities, with a low maternal mortality rate (MMR) being a key component. MMR, defined as the number of maternal deaths per 100,000 live births, is not only a reflection of women's empowerment but is also essential for urban development aligned with the 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 sets a target to reduce MMR to below 70 by 2030.

Global Comparisons of MMR

Studies show that higher-income countries generally have lower MMRs compared to those in the Global South. In 2020, countries such as Germany, Australia, and Sweden recorded maternal deaths of 34, 9, and 5 respectively. Meanwhile, India experienced a staggering 23,753 maternal deaths. Despite a 73 percent reduction in MMR from 2000 to 2020, India’s MMR of 103 remains alarmingly high, especially among disadvantaged groups in urban areas.

India’s Progress and Persistent Challenges in Maternal Healthcare

Policies and Initiatives

India’s significant progress in reducing MMR is largely attributed to policies such as Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram, and Pradhan Mantri Surakshit Matritva Abhiyan. These programs provide financial assistance for institutional births and perinatal care. For example, in Mumbai’s informal settlements, 94 percent of mothers make over three prenatal visits, and over 85 percent have institutional deliveries. However, implementation challenges remain, with MMR plateauing in cities like Chandigarh despite increased institutional deliveries.

Addressing Informal Settlements' Unique Needs

In cities like Jaipur, Jodhpur, Ajmer, and Kota, only 51 percent of mothers from vulnerable groups opted for institutional deliveries due to long wait times and distance from facilities. Additionally, many mothers are unaware of government policies, leading to unnecessary out-of-pocket expenses. The quality of antenatal care is also subpar, resulting in underutilization of reproductive services.

Persistent Challenges Impacting MMR

●      The Inequalities Within Cities

While cities may offer better living conditions and healthcare infrastructure, intra-urban inequalities are stark. The urban poor, particularly those residing in informal settlements, face numerous challenges, including 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 take precedence over healthcare and safety.

●      The Influence of Social Norms and Gender Discrimination

Maternal health outcomes are also influenced by social norms and gender discrimination. Women in informal settlements often face significant barriers to receiving quality care, from societal pressures to healthcare biases. Gender inequality impacts women’s autonomy in making healthcare decisions, as well as their access to necessary nutrients during pregnancy. For instance, 57 percent of mothers in Amritsar’s informal pockets consume fewer than the recommended Iron-Folic Acid tablets during pregnancy, further exacerbating health risks.

●      Delays in Access to Quality Care

Even though urban areas may have better healthcare infrastructure, this does not necessarily translate into equitable access for all. Residents of informal settlements face delays at successive points of care, and in some cases, mothers are forced to deliver at home due to travel constraints, administrative issues, or poor treatment at hospitals. In Western India, for example, 49 percent of mothers do not receive the recommended amount of maternal care due to these challenges.

●      Heterogeneity of Urban Poor Populations

The urban poor are not a homogenous group—they vary in terms of socio-economic status, place of origin, and length of residence in the city. This diversity complicates policy formulation, as a one-size-fits-all approach is often ineffective. Moreover, large gaps in disaggregated data on informal settlement residents, particularly gender-specific statistics, hinder the ability to address these issues adequately.

Existing Global and National Frameworks for Maternal Healthcare

●      Global Toolkits for Improving Maternal Health

Numerous global frameworks have been developed to improve maternal healthcare. For example, WHO’s toolkit targets policymakers and healthcare managers with worksheets, baseline assessment tools, and implementation strategies to address barriers to care. Mauritius offers a toolkit for mothers, providing guidance on perinatal care and child growth. India's Ministry of Health and Family Welfare also has a toolkit for healthcare workers, guiding them through maternal care protocols and benchmarks.

●      Successful Global Strategies

Several countries have implemented successful strategies to reduce MMR. The MANOSHI project in Bangladesh uses community health workers to conduct door-to-door perinatal checkups, while the Maldives reduced MMR by 90 percent between 1990 and 2015 through a review process for maternal deaths. Similarly, Rotterdam addressed non-medical risks like poverty by providing secure housing to perinatal postpartum women, demonstrating that addressing socio-economic factors can significantly impact maternal health outcomes.

●      Lessons from Kampala

Kampala, Uganda, aimed to reduce MMR by 75 percent between 2000 and 2015 but only achieved a 30 percent reduction due to fragmented policy implementation. However, a successful multi-sectoral approach was later adopted, improving referral facilities, increasing ambulance availability, and prioritizing human-centered design. This approach could be beneficial for India, particularly in urban areas where public hospitals are overwhelmed by rural populations seeking comprehensive care.

Strategies for Reducing MMR in Urban India

●      Promoting Community Integration and Collaboration

India can further reduce its MMR by promoting community integration, enhancing health education, and collaborating with researchers and NGOs to identify inequities. Accredited Social Health Activists (ASHA) could adopt guidelines from the MANOSHI program, including building referral systems and setting up help desks in facilities.

●      Addressing Maternal Disparities

Maternal mortality affects women disproportionately, with Black women in the United Kingdom being 3.7 times more likely to die after pregnancy than white women. Addressing such discrimination in India’s maternal healthcare system will require correcting biassed algorithms and sensitising healthcare workers to fair assessment and redressal mechanisms.

●      Tackling Maternal Mental Health

Maternal mental health is a pressing issue, with 22 percent of mothers in India suffering from peripartum depression. Integrating maternal mental health into the National Mental Health Policy, alongside following global models like the Massachusetts Child Psychiatry Access Program for Moms, could help address this issue.

●      Addressing Technology Barriers

Access to technology in low-resource settings remains a challenge, especially with the gender digital divide. However, policies like Digital Public Infrastructure, the Ayushman Bharat Digital Mission, and the National Digital Health Mission can help bridge this gap. Mobile health apps and SMS technology provide affordable alternatives for monitoring pregnant women and improving care quality in informal settlements.

Conclusion

By adopting a combination of global best practices, multi-sectoral approaches, and localized strategies, India can continue to make significant strides in reducing MMR. Addressing the multidimensional challenges of urban areas and ensuring equitable access to maternal healthcare will be crucial in this effort.

Source: ORF India