Unravelling Maternal Health Success of Jharkhand – A Potential Case Study for Positive Deviance

Abstract

Jharkhand has shown significant progress in reducing Maternal Mortality Ratio (MMR) from 371 in 2011 to 56 per 100,000 live births by 2020 which places it alongside the Southern states of India. MMR and TFR data from Sample Registration Surveys (SRS) and maternal and key fertility indicators from National Family Health Surveys (NFHS) were retrieved. We plotted graphically all the states of India based on their MMR and TFR achievements as reported in SRS (2018-20) and explored the reasons of the unique position of Jharkhand’s maternal health achievements. Jharkhand is the only state of India which has achieved the national MMR targets but falls short of national TFR targets. The progress of key maternal health indicators was significant whereas the improvement of key fertility indicators can be considered as work in progress. We examined the possible explanations of the unique position of Jharkhand in terms of health care provision and socio-cultural preferences. To sustain the progress achieved, Jharkhand must focus on behavioural interventions to limit the family size and achieving the national targets of TFR and ensuring respectful maternity care. While the reduction in MMR is promising, focused efforts are needed to reduce TFR by complex socio-behavioural interventions to reduce fertility while continuing the medical interventions for maternal morbidity and mortality.

INTRODUCTION

India is leading the top ten countries which contribute to 60% global maternal deaths, stillbirths and new born deaths. As of 2020, 7,88,000 still births, maternal and new born deaths were reported globally. This was further accentuated by the ongoing COVID-19 which led to massive setbacks in providing health care facilities.[1] The MMR of India has been steadily declining from 122 [95% CI: 112 – 133] in 2015-17 to 97 [95% CI: 88 – 106] in 2018-20 achieving the target of the National Health Policy 2017.[2,3] Similarly, the replacement level Total fertility rate (TFR) of 2.1 has been achieved at national basis by the 2018-20. Once the national target is achieved, it is imperative to examine the figures for sub-national levels (states and district level data), to identify success stories and areas for concern which shall help us achieve the SDG target of MMR (70 per one lakh live births) by 2030.[4]

India as country has achieved the MMR and TFR targets, with many large and populous states like Uttar Pradesh, Madhya Pradesh, Chhattisgarh and Bihar still falling short of national targets is a point of concern. Further, some other states like Uttarakhand, Punjab, Odisha and West Bengal, the TFR is already below replacement level and target MMR is yet to be achieved. For these states, Jharkhand can act as a case study to achieve the national targets.

Jharkhand is one of the eight states categorized as EAG (Empowered Action Group) along with its neighbouring states like Bihar, Chhattisgarh, Odisha, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Rajasthan. This eastern state came to existence after its separation from Bihar on 15 November 2000. It is located on the Chota Nagar plateau and has a rocky terrain which is spread over an area of 79,714 km² and has a population of 32.96 million which makes it the 13^th most populated state in India.[5] The sex ratio is 948 females per 1000 males with overall literacy rate of 66.41% [Males: 76.84%, Females: 55.42%]. Near about 3/4^th population, i.e. 76.95% resides in rural areas. It is a tribal state whereby 26.21% are STs and 12.08% are SCs. There is total 32 tribes in the state, of which 08 are classified as Primitive Tribal Groups (PTG). Santhal is the most populous tribe constituting 32% of total ST population.[6] With a significant proportion of rural and tribal groups come illiteracy, lack of awareness, social stigma, beliefs and taboos.

Jharkhand’s MMR was substantially low from the national average, i.e., 61 (95% CI: 13 – 108), whereas its TFR was higher than the national average at 2.4.[2,7] This pattern makes it an outlier among all other EAG states whose MMR ranged from 101 [95% CI: 51 – 152] in Uttarakhand to as high as 163 [95% CI: 117 – 209] in Madhya Pradesh. On contrary, its MMR of Jharkhand is rather similar to that of Southern states like Andhra Pradesh [58 (21 – 95)], Telangana [56 (12 – 101)], Karnataka [83 (45 – 120)], Kerala [30 (02 – 58)] and Tamil Nadu [58 (27 – 89)], but not in the context of TFR figures.[2]

This has encouraged us to use hand lens to find how and why it is different from its neighbouring states who share similar socio-demographic and geo-spatial features. For this purpose, the present review was carried out to find out the changes that have taken place over the years that could have possibly contributed to reduction of maternal mortality but could not reduce TFR to satisfactory levels.

METHODS

We retrieved MMR and TFR data from last four rounds of Sample Registration Survey (SRS) and key fertility and maternal health indicators from last four National Family Health Survey (NFHS) surveys.[8,9,10] We used the MMR and TFR data from SRS 2015-17 to 2018-20 since data for Jharkhand was not available before 2015.[11,12,13] The key maternal and fertility-related indicators taken into consideration were Current use of any family planning methods among women 15 – 49 years, total unmet need for family planning among women 15 – 49 years, institutional births in the last 5 years before the survey, mothers who had ante-natal check-up in the first trimester, mothers who had at least 4 ante-natal care visits, mothers who consumed iron folic acid for 100 days or more when they were pregnant and mothers who received post-natal care from health care personnel within 2 days of delivery.

The values of TFR and MMR of India and of 19 states were extracted from Sample Registration Survey (SRS) 2018 – 20 report is plotted against the national targets. We used national targets as reference points placed all states in four quadrants, i.e., high TFR – low MMR, high TFR – high MMR, low TFR – low MMR and low TFR – high MMR. Further, TFR and MMR data of India and Jharkhand were extracted from four rounds of SRS starting from 2015 to 17 and plotted as a line diagram to understand the trend of decline.

RESULTS

Jharkhand was the only state in the quadrant of high TFR – low MMR. This shows Jharkhand as an outlier among all where it is the only state of Eastern India which is having the privileged status of low MMR like the Southern states of India but having the disadvantage of high TFR. The states in low TFR – low MMR quadrant were all the states of Southern India namely Kerala, Telangana, Karnataka, Andhra Pradesh, Tamil Nadu and Maharashtra [Figure 1].

Figure 1.

Distribution of TFR and MMR data of 19 states (SRS 2018-20)

The progress in key maternal health indicators over NFHS – 2 to 5 shows a significant improvement which might be the explanation of exemplary achievement on Maternal Mortality Ratio. While the improvement in key fertility indicators are not slow and at best can be considered as work in progress [Figure 2].

Figure 2.

MMR and TFR trend of India and Jharkhand (2015- 2020)

Upon comparing the trend of key maternal and fertility indicators from NFHS data between India and Jharkhand, it was found that the rate of improvement of maternal mortality indicators was higher than fertility indicators. There was over 400% increase in the proportion of institutional births from NFHS – 2 to NFHS – 5 in Jharkhand compared to 163.6% in India and a 57.5% increase in minimum number of ante-natal check-ups in Jharkhand (31.4% in India) during the same time frame. The significant escalation in proportion of ante-natal check-ups in first trimester, consumption of iron folic acid for minimum 100 days and receiving post-natal care within 2 days of delivery in Jharkhand between NFHS – 3 and – 5, showed an increase of 104.8%, 196.8% and 342.9%, respectively. When compared to the national level data, the rate of increase in the same indicators was much less. When the key fertility indicators are considered, there was a 68% reduction in the total unmet need for family planning among women 15-49 years of age in India, whereas the decline was significantly higher in Jharkhand i.e. 82% during the same time period. Although the proportion of current use of any family planning method among women 15-49 years is near about similar during NFHS -5 survey, the rate of increase in Jharkhand (123.5%) was substantially higher in Jharkhand as compared to national level data (38.3%). This shows that even though the maternal mortality indicators are significantly improvising, there is still a lag in the key fertility indicators [Table 1].

Table 1.

Summary of key maternal health indicators (India v/s Jharkhand)

Domains	NFHS 2 (1998-99)		NFHS 3 (2005-06)		NFHS 4 (2015-16)		NFHS 5 (2020-21)
	India	Jharkhand	India	Jharkhand	India	Jharkhand	India	Jharkhand
Current use of any family planning method among women 15 – 49 years (%)	48.2	27.6	56.3	35.7	53.5	40.4	66.7	61.7
Total Unmet need for family planning among women 15 – 49 years (%)	15.8	21.0	12.8	23.1	12.9	18.4	9.4	11.5
Institutional births in the last 5 years before the survey (%)	33.6	13.9	40.8	18.3	78.9	61.9	88.6	75.8
Mothers who had an antenatal check-up in the first trimester (%)	na	na	43.9	33.2	58.6	52.0	70.0	68.0
Mothers who had at least 4 antenatal care visits (%)*	44.2	24.5	50.7	18.2	51.2	30.3	58.1	38.6
Mothers who consumed iron folic acid for 100 days or more when they were pregnant (%)	na	na	22.3	9.5	89.0	15.3	92.0	28.2
Mothers who received post-natal care from doctor/nurse/LHV/ANM/mid-wife/other health personnel withing 2 days of delivery (%)	na	na	36.8	15.6	62.4	44.4	78.0	69.1

*Data for 3 antenatal visits is available for NFHS 2

DISCUSSION

Being predominantly a tribal state, Jharkhand’s health profile is expected to be very much different from non-tribals. This may be attributed to their socio-demographic profile, their customs and traditions which ultimately influences their Health seeking behaviour. The tribals in Jharkhand are a cohesive community, where individuals are closely intertwined with each other. Moreover, tribal women are biologically stronger than non-tribal counterparts, which makes them more resilient to diseases and stressors associated with it.[14]

After gaining the status of an independent state, when the health profile of Jharkhand came to the light, the state government started taking initiatives toward improving the same. The state primarily focused on provision of proven technical interventions like promoting conditional cash transfer schemes such as JSSK and JSY, providing domiciliary care and comprehensive safe abortion care with provision of 4.8% of its budget for health.[15]

Still, as per NFHS -3 data, the health system infrastructure of the state was not performing up to the mark which describes by the maternal health and fertility indicators, ultimately reflected by the MMR and TFR figures. Therefore, government of Jharkhand in its state report in 2004-06 stated areas that need to be strengthened for improving health care facilities. Some of the initiatives were improvement of family planning and institutional delivery services, recruitment of more MBBS doctors and making all the Primary health centres (PHCs) functional. During this time, Jharkhand was the only state where the number of institutional deliveries [21.2% (2002-04) to 17.8% (2007-08)] declined.[15,16] To further improve the health status of people, government of Jharkhand launched Mukhya Mantri Janani Swasthya Suraksha Abhiyan (MMJSSA) wherein beneficiary will receive Rs. 1400/- and Rs. 500/- for institutional and home delivery respectively. Gradually, with the launch of National rural health mission (NRHM) in the state, raising awareness among the people, there was minimal improvement in MMR till 2010.[17]

In the year 2011, TATA steel foundation (TSF), as a part of its Corporate social responsibility (CSR), in association with government of Jharkhand as a public-private-partnership (PPP) initiative, launched project MANSI (Maternal and new born survival initiative) in Jharkhand along with its neighbouring state of Odisha. The main purpose of this programme was to strengthen the community health workers, i.e., Accredited social health activists (ASHAs) (Sahiyyas in Jharkhand) by teaching them low-cost home-based practices to reduce new born, infant as well as maternal mortality. The lack of knowledge of these community activists was a major constraint in delivering health care services to pregnant mothers in rural and tribal areas of Jharkhand. This project also provided health care services at a very low cost to disadvantaged people along with equipping the volunteers with adequate resources to carry out interventions. In the 2^nd phase of this project in 2015, the number of community volunteers (Sahiyyas) increased from 200 to 2400 and a Sahiyya Saathi was appointed to lead a group of 15 to 20 Sahiyyas. In order to improve data management and monitoring of activities, project Sunshine was launched in the 2^nd phase, wherein the Sahiyyas were given android tablets to collect data and report it. Along with the lack of health care facilities and poverty, other factors also contributed to maternal mortality like customs, beliefs and patriarchal families. To address this, the husbands and mothers-in-law were also target for education regarding women’s health and child birth issues. In the 3^rd phase, MANSI PLUS was launched in 2018, where adolescent health, teenage pregnancies, right marriageable age and malnutrition (life cycle approach) were also incorporated.[18,19]

Following all technical interventions, a sudden change in the pattern of health indicators was observed from NFHS 4 onward. Near about 50% of women received post-natal care. The proportion of institutional births were tripled i.e., 61.9% and as many as 69.6% births were now attended by doctors/Lady Health Visitors (LHVs). All these factors marked a significant decrease in MMR to 76/1,00,000 births.[9] In subsequent years, with continuous provision of health facilities, Jharkhand witnessed an increase in proportion of women receiving at least 4 ANCs twice as that of NFHS-3, i.e., 38.6%. With more than 3/4^th of deliveries being conducted at health facilities and more than 80% births assisted by doctors/LHVs, the MMR further reduced to 56/1,00,000 live births, which is much lower than the national average of 97/1,00,000 live births.[3,13]

There was also a steady decline in TFR from 3.3 to 2.4 which might be attributed to increased adoption of family planning methods from 35.7% to 61.7%, reduction in total unmet need of contraception from 27.6% to 11.5%.[15,16,17] This decrease commensurate with the decline in MMR. If the existing interventions continue to be implemented, then in upcoming years it is expected that the health indicators will further improve, particularly the fertility indicators. This remarkable change in Jharkhand shows that despite the odds of societal taboos, adherence of the community to their behavioural patterns, with carefully planned programs, the desired targets can be achieved in a time bound manner.

The achievements of Jharkhand are a potential case of positive deviance which can influence the neighbourhood states to achieve the targets of maternal and fertility indicators with limited resources and focused interventions. The unique challenges of Jharkhand such as large number of tribal population and difficult terrains were used gainfully by the department for achieving the targets. The resilience and cohesiveness of tribal women were used for health promotion and safe motherhood programmes by introducing ‘Sahiyyas’ from the same community for improvement of reproductive and maternal health. Further, the mineral rich state used the large potential of corporate social responsibility (CSR) of industries for betterment of communities which was scaled up in successive years to a state-wide programme. The success stories of Jharkhand can be tweaked to the local context and can be implemented in other states who are still struggling to achieve the maternal health targets.

CONCLUSION

The current strategies in Jharkhand have paid the dividends in terms of reducing maternal mortality. With the higher TFR, the reduction in maternal mortality might be temporary and now the efforts have to be shifted to behavioural interventions to achieve the national target of TFR.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.