rjmchn mission - maharashtramahades.maharashtra.gov.in/files/publication/unicef_rpt/chap4.pdfhealth...

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Maternal and Child health

4

Health is one of the indicators that measures human development. Maharashtra has

created extensive health-related infrastructural facilities, has trained health personnel

and is generally considered to be above the national average.

The levels and trends of health status in Maharashtra are reflected in infant mortality

and life expectancy at birth, which has shown substantial improvement over the years

and are better than a number of states in India. However, there are marked inter-district

variations in health achievements and some of the districts are comparable to the

worst-placed states of the country.

Public expenditure on health and family welfare in Maharashtra is relatively low in

comparison to the GSDP of the state. States like Kerala and Tamil Nadu, which have

lower GSDP than Maharashtra, spend more on health and family welfare both in per

capita terms as well as a share of GSDP.

42 | MATERNAL AND CHILD HEALTH

Overview

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Government health infrastructure (March,2010) Human resources in government health facilities (March,2010)

• Overall 22% posts are vacant and vacancies are higher for posts like medical officers

and specialists

• There are 1,03,975 Allopathic, 16,636 Dental Surgeons and 1,22,451 AYUSH doctors

are registered in Maharashtra

Source: Health Status, Maharashtra, 2010,SHSRC,Maharashtra

Source: Health Status,Maharashtra,2010, SHSRC, Maharashtra and Rural health statistics, 2010, MoHFW

Type of institution

Number of health institutions

Bed strength

Average population covered (Rural population 2001)

Building required to constructed

Shortfall of facilities

State level Hospitals

498 NA - - -

District Hospitals

23 6,085 - - -

Sub District Hospitals with capacity of

a) 50 beds 56 2,800 - - -

b)100 beds 23 2,300 - - -

c)200 beds 3 600 - - -

Rural Hospitals (CHCs)

386 11,280 1,52,815 28 131

Primary Health Centres

1,816 1,816 30,715 146 168

Other hospitals 253 7,135 - - -

Sub Centres 10,580 - 5,272 2,238 1,573

Category of post Sanctioned Filled Percentage of filled post to total sanctioned post

Class-1 Specialists 519 389 75.0

Medical officer Grade A and B

9,025 7,068 78.3

Nursing post 24,114 22,018 91.3

Health Assistants 4,600 3,609 78.5

Multipurpose Health Worker (Male)

12,210 9,596 78.6

Lady Health Visitors (LHV) 2,172 1,918 88.3

Multipurpose Health Worker (Female)/ANM

12,592 12,114 96.2

Pada Swayamsevak 11,482 8,130 70.8

ANM/LHV/Staff nurse under NRHM

15,226 8,598 56.5

Posts under RCH-2 in urban area

2,799 766 27.4

Total 94,739 74,206 78.3

MATERNAL AND CHILD HEALTH | 43

Crude Birth Rate34 (CBR) Crude Death Rate35 (CDR)

• As per Sample Registration System (SRS) estimations, Crude Birth Rate (CBR) for

Maharashtra was 26.3 in 1990 and decreased sharply to 17.6 in 2009. Birth rate was

slightly higher in rural areas (18.1) compared to urban areas (16.9)

• CBR for Maharashtra is very low compared to the national level (22.5). Among bigger

states, only four - Kerala , Punjab, Tamil Nadu and West Bengal have a CBR lower than

Maharashtra

• The state health department estimated CBR at 17.3 through Survey of Causes of

Deaths (SCD) for 2009 in rural areas, which is slightly lesser than the SRS estimation.

CBR varied across districts and was lowest in Sindhudurg district (12.2) and highest in

Nandurbar district (21.1)

• While CBR is less than 15 in seven districts (Amravati, Chandrapur, Gondiya, Kolhapur,

Ratnagiri, Sindhudurg and Wardha), it is higher than 20 in three districts (Jalna,

Nandurbar and Thane)

• As per SRS estimations, Crude Death Rate (CDR) for Maharashtra was 7.8 in 1990 and

decreased sharply to 6.7 in 2009. Death rate is very high in rural areas (7.6) compared

to urban areas (5.5)

• CDR for Maharashtra is very low compared to the national level (7.8). Among bigger

states, only five -Delhi , Punjab, Haryana, Jammu & Kashmir and West Bengal have

CDRs lower than Maharashtra

• The state health department estimated CDR at 6.6 for 2009 in rural areas, which

is lesser than SRS estimations. CDR varied across districts and is lowest in Hingoli

district (4.9) and highest in Sindhudurg district (10.0)

• It is interesting to note that lowest crude birth rate and highest crude death rate in the

state is in Sindhudurg district

• While CDR is less than 5.5 in three districts (Ahmadnagar, Hingoli and Thane), it is

higher than 8 in five districts (Gadchiroli, Ratnagiri, Satara, Sindhudurg and Wardha)

Source: SRS, 2009, RGI, Government of India and Health status, Maharashtra, 2010, Survey of Causes of Deaths Scheme (Rural), State Bureau of Health Intelligence and Vital Statistics, Pune, Annual Report, 2009

Source: SRS, 2009, RGI, Government of India and Health status, Maharashtra, 2010, Survey of Causes of Deaths Scheme (Rural), State Bureau of Health Intelligence and Vital Statistics, Pune, Annual Report, 2009


Total Fertility Rate 36 (TFR), Maharashtra Total Fertility Rate (TFR), rural areas, by districts, Maharashtra, 2009

• According to Sample Registration System (SRS)37, Total Fertility Rate (TFR) for

Maharashtra is 1.9, which is below the replacement level, and lower than the national

average (2.6). Among bigger states, only two, Kerala and Tamil Nadu, have lower TFR

than Maharashtra and four others, Andhra Pradesh, Himachal Pradesh, Punjab and

West Bengal, are at the same level.

• TFR in urban areas (1.8) is significantly lower than rural areas (2.1).

• Maharashtra has achieved the TFR target set for the Eleventh Five Year Plan (1.9) and

National Population Policy, 2000 (2.0).

• The state Health department estimated TFR at 2.14 through SCD for yars 2009 in rural

areas, which is slightly higher than SRS estimations

• There is a significant disparity in TFRs across the districts, specially between

Aurangabad and Konkan division

Source: Compendium of India’s fertility and mortality indicators, 1971-2007 based on SRS, RGI, Govt. of India, 2009

Source: Survey of Causes of Deaths scheme (Rural), State Bureau of Health Intelligence and Vital Statistics, Pune, Annual Report, 2009

State average: 2.14

Highest: 2.67 Jalna

Lowest: 1.59 Chandrapur

Index

Not available

Less than 1.90

19.91-2.10

2.11-2.30

More than 2.30

No. of districts

02

07

09

06

11


Life expectancy at birth38, Maharashtra Trends in Maharashtra’s Infant Mortality Rate 39 (IMR)

• Life expectancy at birth (LEB) for Maharashtra is 67.2 years and is higher than the

national average (63.5 years). Among bigger states, only Kerala and Punjab, have a

higher LEB than Maharashtra.

• LEB was only 53.8 years during 1970-75 and reached 62.6 years in 1986-90. It

reached 67.2 years in 2002-06 and has increased by 6 to 7 years during last 20 years.

• Female LEB is higher (2.4 years ) than male LEB and difference in female and male

LEB is steady in last 20 years.

• Urban LEB is significantly higher (5.9 years) than rural areas and difference in urban

and rural LEBs has slightly increased in the last 20 years.

• Maharashtra’s Infant Mortality Rate (IMR) has decreased by 17 points between 2000

and 2009.

• The state is far from achieving the Eleventh Five Year Plan target (17).

Source: Compendium of India’s fertility and mortality indicators,1971-2007 based on SRS, RGI, Govt. of India, 2009

Source: SRS, RGI ,Government of India


State -wise comparison of IMR, 2009 IMR by sex and area, Maharashtra, 2009

Maharashtra’s rank with reference to IMR

Maharashtra’s IMR is very low compared to the national average. Among bigger states,

only Kerala and Tamil Nadu have an IMR lower than Maharashtra.

• While the difference between rural and urban IMRs at the national level is 21 points,

it is only 15 points in Maharashtra.

• While the difference between male and female IMRs at the national level is 3 points,

in Maharashtra it is 5 points.

Source: SRS, RGI , Government of India, 2011

Source: SRS, RGI, Government of India, 2011

Group All states and UTs (35)

In bigger states (19)

Total 11 3

Male 10 3

Female 12 3

Rural 15 4

Urban 10 2

National average: 50

Lowest: 11 (Goa) and 12 (Kerala)

Maharashtra: 31

Highest: 67 (Madhya Pradesh)

Index

Less than 27 11-27

28-35 28-35

36-50 36-50

More than Indian

average (50) 51-67

No. of districts

09

07

10

09


IMR, rural areas by districts, 2009 How many infant deaths do we need to prevent in Maharashtra?

Total number of ANC cases registered : 21,87,903

Total number of projected live births : 20,12,871

Source: Calculation based on IMR, 2009, SRS for year 2009

(Source : Health department, GoM)

• In 2009, as per the state Health department estimations Maharashtra’s IMR was 29

through SCD for year 2009 in rural areas, while as per the SRS estimations it was 37.

• Special attention is required in 5 districts where IMR is more than 35.

We have to save lives of more than 28,000 infants in a year,

which is 45% of current infant deaths

Source: Survey of Causes of Deaths scheme (Rural), State Bureau of Health Intelligence and Vital Statistics, Pune, Annual Report, 2009

Low performing five districts-

Wardha: 44

Washim, Yavatmal and Bhandara: 37

Nandurbar: 36


Number of infant deaths as per current IMR

Number of infant deaths if IMR is 17 as per the XI Five Year Plan target

Number of infant deaths to be prevented

In a year 62,399 34,219 28,180

In a month 5,200 2,852 2,348

In a day 171 94 77

State average: 29

High performing three districts-

Sangli: 16

Kolhapur: 19

Chandrapur: 21

Index

Not available

25 or Less than 25

26-30

31-35

More than 35

No. of districts

02

11

07

10

05

Under-five mortality rate40, 2009 Share of under-five mortality rate, 2009

Source: SRS, RGI , Government of India, 2009

• Under-five mortality rate (U5MR) of Maharashtra is very low compared to the national

average.

• While the difference between rural and urban U5MRs at the national level is 30

points, in Maharashtra it is only 17 points.

• While the difference between male and female USMRs at the national level is 9

points, in Maharashtra it is 8 points.

Source : SRS Statistical report , RGI , New Delhi, 2009

65.6 % under-five deaths occur within first four weeks of birth

Infant deaths within 7 days of birthNeonatal deaths

65.6%Infant deaths

84.8%

54.6%

11.0%

19.2%

19.2%

Infant deaths between 7 days of birth and within 29 days

Infant deaths between 29 days and within one year of birth

Child deaths between one year and within five years of birth


Top ten causes of child death in the category of other states* (0-4 years)

Causes of child death in the category of other states

*States have been grouped in two major categories in the country. First category comprises of the Empowered Action Group (EAG) which comprises of states of Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa , Rajasthan, Uttar Pradesh and Uttarakhand and Assam state. Second categories covers the remaining states and is known as other states.

Source: Report on Causes of Death in India 2001-2003, RGI, New Delhi

• Of the total deaths taking place, 12% are from the 0-4 year age group.

• Perinatal conditions are dominant causes of child death followed by respiratory

infections and diarrheal diseases in 0-4 year age group.

• Male child deaths are more due to perinatal conditions compared to female child

deaths indicating that biologically females are stronger.

• 6% of total deaths occur during 1-4 years and diarrheal disease is dominant (21.1%)

cause of child death followed by respiratory infections (18.5%).

• Unintentional injuries (18.9%) and diarrheal diseases (14.5%) are main reasons for

child death in the 5-14 year age group.


Rank Causes of death Male Female Total

1 Perinatal conditions 43.4 34.6 39.2

2 Respiratory Infections 16.3 18.5 17.4

3 Diarrhoeal diseases 10.5 13.2 11.8

4 Other infectious and parasitic diseases

6.3 8.0 7.1

5 Congenital Anomalies 5.1 4.5 4.8

6 Unintentional injuries 4.6 4.0 4.3

7 Symptoms, signs and ill-defined conditions

3.7 4.7 4.2

8 Nutritional deficiency 1.8 2.2 2.0

9 Fever of unknown origin 1.7 2.4 2.0

10 Malaria 1.3 1.7 1.5

Gan

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Trends in Maternal Mortality Ratio41 (MMR), India and Maharashtra

Source: Family Statistics in India, 2009,MOHFW, 2009 and SRS special bulletin, 2011, RGI, New Delhi

• MMR has reduced sharply both at the national and state levels. Maharashtra’s MMR

is very low compared to the national level. Only two other states, Kerala and Tamil

Nadu have MMRs lower than Maharashtra

• Sharpest decrease in MMR (26 points) was between 2004-06 and 2007-09

• Maharashtra’s MMR is close to the target set for the Eleventh Five Year Plan (100)

Gan

esh

Kum

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igam


Percentage of girls marrying before 18 years of age, 2007-08

Adolescent girls Birth order 3 or more, 2007-08

Percentage of births to women during age 15-19 years out of total births, 2007-08

Source: DLHS,2007-08

Source: DLHS, 2007-08

• 26.1% girls 15-19 year age group and

0.7 % girls in 10-14 age group are

married.

• 17.6% girls are married below the legally

permissible age and wide disparities

exist between Nagpur/Konkan and

Nashik/Aurangabad divisions.

• Percentage of births to women during

15-19 year age group is 9.7% and varies

across districts. Wide disparities exist

between Nagpur/Konkan and Nashik/

Aurangabad divisions.

• Percentage of births to women during

15-19 years to total births is highly

significant to percentage girls marrying

before 18 years.

• Birth order 3 or more is very high in ST social group and lowest wealth index.

• Some districts of Aurangabad and Nashik divisions and tribal districts (Nandurbar,

Gadchiroli ) have high level of birth order 3 or more.

(U- Urban, R-Rural, SC- Schedule Caste, ST-Schedule Tribe, OBC- Other Backward Community, L- Lowest wealth quintile, H- Highest wealth quintile)


Index

Less than 10%

10-15%

15-20%

More than 20%

No. of districts

13

05

04

13

Index

Less than 10%

10-17.5%

17.5-25%

More than 25%

No. of districts

09

08

08

10

Index

Less than 20%

20-25%

25-30%

More than 30%

No. of districts

08

11

08

08

Adolescent Girls: Percentage of women 15-19 years , who have begun childbearing (teenage pregnancy)

Couple Protection Rate42 (CPR), 2007-08

Source: NFHS, 2005-06

Source: DLHS,2007-08

13.8% girls in the age group of 15-19 years have begun child bearing and incidence is

significantly higher in girls belonging to rural areas, SC and ST social groups and lowest

wealth index group.

• CPR is low among ST social group and lowest wealth index group.

• Some districts of Aurangabad division and tribal districts (Nandurbar, Gadchiroli and

Thane) have low CPR.

Index

Less than 60%

60-65%

65-70%

More than 70%

No. of districts

08

08

09

10


• Antenatal Care (ANC) registration within first trimester is low among ST social group

and lowest wealth index group.

• Some districts of Aurangabad and Nashik divisions and tribal districts (Nandurbar,

Gadchiroli ) have low level of ANC registration.

• Only 43.8% women used Government ANC checkup facilities in the state. However,

in Gadchiroli and Gondiya districts more than 70% women used Government ANC

check up facilities.

• Three ANC checkups are lower in rural areas, ST social group and lowest wealth index

group.

• Almost all districts of Aurangabad and Nashik divisions have had less than 70%

women going for three ANC checkups and these figures compare very low to those

from districts of Pune and Konkan divisions.

• Only 33.9% women, who had live birth, received full ANC checkups (At least three

visits for Antenatal Check-up, at least one Tetanus Toxoid (TT) injection received and

100+ Iron Folic Acid (IFA) tablets/ syrup consumed).

ANC registration in first trimester, 2007-08 Three ANC checkups, 2007-08


Source: DLHS, 2007-08Source: DLHS, 2007-08

Index

Less than 60%

60-65%

65-75%

More than 75%

No. of districts

09

09

12

05

Index

Less than 70%

70-80%

80-90%

More than 90%

No. of districts

11

07

13

04

• Percentage of safe delivery is low in rural areas, ST social group and lowest wealth

index group. Compared to districts from Pune and Konkan divisions where safe

delivery percentages are high, some districts of Amravati, Nashik and Nagpur

divisions have less than 70% safe deliveries.

• Substantial differences were observed in mean delivery cost in Government (Rs.

1,690) and private facility (Rs. 6,282).

• 75.5% mothers in Mahararshatra have had a postnatal checkup done within two days

of childbirth. This percentage is low in rural areas, ST social group and lowest wealth

index group.

• Less than 65% women in three tribal districts of Nandurbar, Gadchiroli and Dhule

have had postnatal checkups done within two days of childbirth.

• Disparities exist between districts of Pune/Konkan divisions and Aurangabad,

Amravati and Nashik divisions.

Percentage of safe delivery43, 2007-08 Postnatal check up within two days of delivery, 2007-08


Index

Less than 70%

70-75%

75-80%

More than 80%

No. of districts

13

08

05

09

Index

Less than 65%

65-75%

75-85%

More than 85%

No. of districts

03

10

13

09



• 69% children are fully immunized. While no significant difference exist across the

areas and sex, differences are significant among social groups and wealth index

groups.

• Percentage of fully immunized children is significantly low in Nashik division and

Gadchiroli district.

• Highest dropout (17%) is between BCG and DPT-3 vaccination.

• 86% children got vaccinated at Government health facilities.

All basic vaccinations (full immunization44), 2007-08

Diarrhoea

Childhood diseases, 2007-08

Acute Respiratory Infection (ARI)




Index

Less than 60%

60-70%

70-80%

More than 80%

No. of districts

05

07

12

11

Index

Less than 15%

15-25%

25-30%

More than 30%

No. of districts

10

10

08

07

Index

Less than 10%

10-12.5%

12.5-15%

More than 15%

No. of districts

13

08

08

06

Source: National Health Accounts INDIA, 2004-05, MOHFW

Expenditure in health, Public and private, 2004-05

• 44.2% children suffering from diarrhoea were given ORS.

• Disparities exist between Konkan /Pune divisions and other divisions with reference

to childhood diseases.

• It is estimated that in the Health sector, the share of private expenditure is 83% of

the total expenditure in Maharashtra and it is higher as compared to the national

average (78%).

• Per capita private expenditure is five times more than per capita public expenditure.

• Per capita public expenditure in Maharashtra is lower than the national average.

• In fact Maharashtra’s per capita expenditure is lower than Punjab, Himachal Pradesh,

Karnataka, Kerala and Tamil Nadu.

Source: National Health Accounts INDIA, 2004-05,MoHFW and Budget estimates 2011-12

* Revised, $Estimated

Trends in budget provisions for health, Government of Maharashtra

• Maharashtra’s expenditure on health has varied across the years and it has been

very low compared to many other states like Gujarat, Tamil Nadu, Kerala, Karnataka

and West Bengal. However, the state’s Health budget in absolute terms has more

than doubled from Rs. 2318.70 crore in 2005-06 and to Rs. 4863.73 crore for 2011-12

(estimated).

Diarrhoea ARI

Women with knowledge of the disease 75.0% 28.9%

Children suffering from 19.9% 12.9%

Children who sought advice/treatment 77.9% 84.6%


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