Measurement and mapping of maternal health service coverage through a novel composite index: a sub-national level analysis in India

Reducing the maternal mortality ratio is a pivotal target as part of the ‘Sustainable Development Goal 3’, which affirms ‘to ensure healthy lives and promote wellbeing for all at all ages’ [1]. Maternal mortality is a crucial health indicator largely resulted from causes which are preventable and treatable [2]. Maternal health, which refers to the health status of a woman during the period of pregnancy, childbirth, and postpartum [3], has the potential of affecting significant maternal and child health outcomes, therefore the domain of maternal health assumes a pivotal role from the development perspective of a nation. Health system strengthening in terms of increased quality of care, health infrastructure, finance, and human resources can help bolster the maternal health service coverage, which in turn can have multiple positive implications on maternal, neonatal and child health statuses. The government of India has initiated many schemes and programmes to improve accessibility, affordability and quality of maternal health service coverage across the country [4‐6]. Reaffirming its commitment towards achieving better maternal health outcomes, the Indian government, under the National Health Mission (NHM), introduced a novel strategic approach for ‘Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A)’ [7]. This ‘continuum of care’ of RMNCH + A refers to an integrated health service accessible to women, neonatal, infants or adolescents over the dimension of time (before pregnancy, during pregnancy, childbirth and postnatal) and place (family and community care, outpatient and outreach services and hospital and health facilities) [8]. Maternal health thus, is one of the key thematic areas under the strategy of RMNCH + A, which aims to promote linkages between diverse health interventions to reduce maternal, neonatal and child mortality rates.

According to a guideline by the Indian Ministry of Health and Family Welfare (MoHFW), based on the time dimension, the health care services for a pregnant woman are classified mainly into three types, namely; antenatal/ prenatal care, intranatal/intrapartum care, and postnatal/postpartum care [3]. Antenatal care (ANC), which refers to the systemic care and supervision recommended for women during their pregnancy, is largely a platform for preventive and promotive health care services. ANC primarily aims to monitor the progress of fetal growth and wellbeing of the mother and fetus, thereby facilitating the timely management of obstetric complications. MoHFW guidelines recommend a minimum of four ANC visits in which the ANC registration and first ANC checkup within the first trimester (within 12 weeks) are accorded a high priority [3]. The World Health Organization (WHO) recommends various interventions ranging from dietary counselling, nutrient supplementation, and essential screening tests to improve the utilization and quality of antenatal care [9]. Another important stage of care in the continuum of RMNCH + A is intranatal/ intrapartum care (INC), which refers to systemic care for a pregnant woman during labour and delivery [3]. The time of birth is considered extremely crucial for both mother and the child as the chances of complications are high during this stage [10]. Sufficient literary evidence supports the prevalence of high-risk pregnancy and pre-term birth among the Indian and other south Asian populations [11‐15]. Therefore, the delivery of the baby crucially requires an appropriate setting, where lifesaving equipment is available and hygienic conditions are fully maintained. Utilization of public, private or charitable trust/Non-Governmental Organization health facilities during labour and childbirth, referred to as Institutional delivery, is a significant means of timely management of obstetric complications [16]. However, literature reported that a considerable proportion still deliver at home in India attributed to social, cultural, physical and financial factors [17]. Increased skilled birth attendant (SBA) coverage is associated with a reduced probability of maternal deaths [16], especially for those women who prefer to deliver at home in India. The third stage of care is the postnatal/postpartum care (PNC), which involves systemic care of women after delivery, where the first 42 days (6 weeks) are conventionally treated as the postpartum period [3]. MoHFW guideline recommends at least three postnatal visits to the health facility after an uncomplicated normal institutional delivery in India. Evidence indicates that a larger proportion of neonatal deaths occurs in the first week of postnatal, with the highest number in the first three days [18].

To date, limited literature exists on the measurement of maternal health service coverage at the sub-national level in India. Prior research mainly focused on the theme of Reproductive, Maternal, Newborn and Child Health (RMNCH) service coverage and their inequities at national and sub-national levels in India. The majority of them used Coverage Gap Index (CGI) as an outcome measure of the RMNCH service coverage, which is primarily constituted by the domains of reproductive services, maternal and newborn care, immunization and management of illness [19‐21]. However, there were only two indicators, namely ‘skilled birth attendant’ and ‘antenatal care coverage’ under the domain of maternal and newborn care, which makes the measurement of maternal health service coverage narrow and incomplete. To the best of our knowledge, no published study has estimated and examined maternal health service coverage using a composite index. The present study addresses this lacuna by constructing a comprehensive ‘Maternal Health Service coverage Index’ (MHSI), which includes a cumulative set of relatively large maternal health indicators categorized into three domains of antenatal, intranatal and postnatal care coverage, which is a major highlight of the study. The use of a composite index value would help us estimate the maternal health service coverage for a particular country/ state and compare them. The MHSI, as a summary measure, will reduce the reporting burden and help in expediting the systematic monitoring of maternal health service coverage in large entities like states and countries. Further, the constructed MHSI has been used for the identification of the low, medium and high coverage regions across different time series points in India, a theme which was largely unexplored in the previous studies. This shall help states identify lagged areas, introduce targeted interventions and prioritize the areas (antenatal, intranatal and postnatal care) to be intervened. Therefore, in this backdrop, utilising a nationally representative data, the specific objectives of the study are outlined as; a) to comprehensively measure maternal health service coverage at the sub-national level in India by constructing a composite index using a rigorous methodology; b) to map and categorize India into low, medium and high maternal health coverage zones; c) to examine the sub- national areas (states and union territories of India) which have transitioned from low to higher category of coverage and vice versa across the different time points.

Out of the 15 maternal health service indicators, institutional delivery (INC indicator), immunization against tetanus, ANC checkups and IFA supplementation (ANC indicators) recorded a relatively higher mean percentage (more than 70%) coverage at all India level for three years (2017–18 to 2019–20). Maternal health care services like institutional delivery and antenatal care coverage in India observed substantial progress in the past two decades with the implementation of plethora of targeted government driven programmes such as the National Health Mission (NHM), Maternity Benefit programmes like Janani Suraksha Yojana(JSY), Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) and Pradhan Mantri Matru Vandana Yojana (PMMVY) to name a few [4, 5, 33]. Recently launched ‘Anemia Mukt Bharat’ programme has given prime importance to IFA supplementation for pregnant women, which is a highly probable reason for enhanced IFA coverage [34]. However, the national mean percentage coverage of some of the indicators of maternal health service coverage is quite perturbing, such as; screening for diabetes (ANC indicator), SBA attended home deliveries, c-section delivery and treatment for obstetric complications (all INC indicators) as they recorded relatively low mean percentage (around 30%) coverage across the country. Some state specific studies recorded prevalence of gestational diabetes ranged from 9.89% to 35% [35‐39], which is quite alarming. In this regard, in compliance with the recommendations of WHO and the International Association of Diabetes and Pregnancy Study Group (IADPSG), India requires region specific efforts to expand its coverage of screening for diabetes among pregnant women [38]. Though the present study observed lower mean percentage coverage for c-section delivery across India, nevertheless the growth rate of c-section delivery in India has doubled during 2005–06 to 2015–16 [40]. Low socio-economic status, awareness of available schemes, distance to the health facility, absence of transport, and social cultural norms can be identified for preference of home delivery and related maternal complications in India [41‐44].

Both southern and western zones of India have outperformed the other zones on the coverage of a number of maternal health indicators. South zone, particularly has performed sizable well with respect to institutional deliveries, IFA supplementation, ANC checkups and screening for HIV [45‐48]. The states of Kerala, Tamil Nadu, Karnataka and Andhra Pradesh from the south zone are the front runners in the overall ‘Sustainable Development Goals’ (SDGs) with relatively high SDG index scores, which has remarkably influenced their coverage and receipt of health care services such as institutional care and antenatal care coverage [49]. Consistently high HIV prevalence districts were clustered mainly in the south zone of the country [50], therefore, it is expected to have high percentage coverage in screening for HIV as a preventive measure. Furthermore, most of the states from south zone are known for their remarkable performance in literacy rates, particularly in female literacy [51], which can be a possible reason for increased awareness of HIV screening among south zone population. West zone particularly has recorded a substantial high coverage for immunization against tetanus, ANC registration, calcium supplementation and anemia treatment coverage. Effective planning and management of resources, re-establishment of outreach services, community links, supportive supervision and monitoring are the possible facilitating factors of immunization services including tetanus [52]. State governments of Gujarat, Chhattisgarh and Madhya Pradesh from the west zone have collaborated with WHO for calcium supplementation to pregnant women [53] possibly the reason for high ‘calcium supplementation’ coverage in the west zone.

North zone recorded the lowest coverage for indicators particularly with respect to screening for HIV and SBA attended home deliveries. Low female literacy and rigid socio-cultural factors of the majority of states from the north zone may have resulted in low SBA attended home deliveries [51]. However, Uttar Pradesh and Rajasthan from the north zone are observed to be the states which require the highest need for ‘Prevention of Maternal to Child Transmission’ (PMTCT) of HIV [54] and therefore demands high coverage in screening for HIV among pregnant women. East & north east zone has underperformed on a number of indicators, specifically for screening pregnant women for diabetes, c-section delivery and treatment for obstetric complications. The low female literacy rate [51] and the high proportion of tribal population [55] are expected to account for low c-section delivery rates in this zone. Majority of states from the east & north east zone recorded a low prevalence of diabetes in a nationwide study [56], making it a likely cause for low diabetes screening coverage. Inaccessible regional terrain, poor transportation facilities, availability of prompt medical services and behavioural factors (tobacco and alcohol use) are significantly associated with a low treatment coverage for obstetric complications [57].

The methodology adopted in the present study for data normalization and construction of MHSI is primarily based on United Nations Development Programme (UNDP)’s procedure to compute Human Development Index (HDI) [58], which is highly rigorous and standardized. Further, the study generated MHSI scores based on the choice of arithmetic mean and geometric mean approach for aggregating the 15 indicators into one composite index. The geometric mean approach (used in scenario IV) has an advantage over the arithmetic mean approach (used in scenario I) as it is less affected by skewed data and extreme values, thereby integrating the overall balance in the data distribution [31]. However, the usage of arithmetic mean is more suitable in those cases where the data normalization is carried from the observed values of the data distribution [32]. Therefore, comparison of index values across these two different approach-based scenarios are redundant in nature. We clarify that the study elucidates the comparison of MHSI values across two time periods (base year and reference year) within a given scenario and not across the two scenarios. Construction of MHSI for these two particular scenarios, facilitates the identification of those common states/union territories/regions, which have transitioned form a lower to higher category of maternal health service coverage or vice versa. The earlier attempts to measure maternal health service coverage have been limited and narrow in their approach. Composite Coverage Index (CCI), which comprised essential health interventions of RMNCH continuum of care [59], included only two indicators i.e., ‘skilled birth attendant’ and ‘antenatal care coverage’ under the domain of maternal and newborn care. In contrast, the present study specifically emphasized on maternal health service coverage rather than considering the consolidated RMNCH coverage as studied in the previous literature [19‐21, 59, 60].

Different states/UTs/zones in India have performed variedly as far as MHSI scores are concerned. The UTs of Dadra & Nagar Haveli and Chandigarh showed upward transition of the MHSI category in both scenarios (I and IV). Dadra & Nagar Haveli transitioned from medium to high category and that of Chandigarh showed low to medium category. This might be likely due to the concentrated efforts of respective governments and also partly because these UTs are the front runners or performers in specific SDGs related to poverty, health, quality education and economic growth [49]. The state of Maharashtra and Assam showed an upward transition in both scenarios from medium to high MHSI category, while Jharkhand showed upward transition from low to medium category. Assam and Jharkhand have remarkably improved its maternal health outcomes and have recently been accorded a position of ‘achiever’ in a health index released by the National Institution for Transforming India (NITI) Aayog, which is the Indian government’s apex think tank [61]. While, the state of Maharashtra is a frontrunner across various dimensions of NITI Aayog’s health index. On the other hand, the state of Mizoram and the UT of Puducherry displayed downward transition in both scenarios. This might be due to relatively less coverage on a number of indicators like IFA supplementation [62], diabetes screening [56, 63], ANC checkups and treatment of obstetric complications. Out of the 4 zones, only the west zone transitioned upwards in the reference year from the medium to high MHSI category. The state of Goa and Maharashtra and the UT of Dadra and Nagar Haveli from the west zone performed substantially well, which gave an upsurge in the MHSI scores of the west zone. None of the zones showed downward transition across two time points for both the methodological scenarios. Region/state/UT specific health interventions are required to be undertaken to target low coverage indicators of maternal health for bolstering their performance to achieve positive incremental changes in maternal health outcomes over time.

The present study faces some limitations. The present study is based on the HMIS data that allows undertaking temporal analysis and over time incremental changes, nevertheless some issues still remain in terms of data quality and therefore the results of the present study should be cautiously used. Consideration of private sector, which reports at a lower rate than the public sector to the health facility data like HMIS, may affect the numerators of the MHSI individual indicators especially for the states with a greater predominance of private sector. Therefore, readers have to be watchful while drawing and generalizing the conclusions. There might be inherent issues with some HMIS derived denominators used to calculate the coverage estimates. The denominators indicates those females who were registered for a maternal services for instance ‘Total number of pregnant women registered for ANC’. It excludes that population who have not been registered for the said maternal service or did not seek maternal health care elsewhere. Those women might be marginalized, more vulnerable and lesser health status. This can lead to selection bias depending on proportion of women registered for any service. The external validation of MHSI individual indicators from HMIS data with that of state specific data or NFHS data and alike should be undertaken for better generalizability, which forms the future scope of this study. Besides, due to limited data availability at the sub-national level, the analysis pertains to a short time span of three years (2017–18 to 2019–20), hence the incremental changes in the maternal health service coverage reflect only the preliminary estimates, therefore should not be used to draw inferences for long term policy purposes. More time series data is required to confirm and substantiate the inferences of these short time series-based results. This leaves a lot of scopes for future research to undertake longitudinal analysis concerning the theme of the present study. Though the composite ‘Maternal Health service Index’ computed in the study involves a set of 15 indicators, which is relatively larger than the previous studies, however; data on only one indicator (postpartum checkup) was available and classified under the domain of postnatal care, which makes this domain under-represented for constructing the index. The government of India has initiated a number of schemes especially for nutritional interventions of pregnant and lactating women [64, 65] for antenatal and postnatal care. In this light, besides postpartum checkup, which is a globally recognised indicator [66], data on more indicators like nutritional support, screening for psychological wellbeing after delivery [67] and alike should be disseminated on the government portal for better representation of the PNC domain, which is an important food for thought for a revised version of this novel index in future. Additionally, though the study included ‘c-section delivery’ as an important indicator under the domain of intranatal care; nevertheless, the states need to be cautious and should take into account the trend/ prevalence of high-risk pregnancy, obstetric complications and evolving concept of maternal choice/decision while taking a decision on the inclusion of particular indicators like c-section delivery as a coverage indicator as all the women are not in need c-section delivery. Although the study envisioned to examine each and every state as well as union territories, however the two union territories of Daman & Diu and Lakshadweep were excluded from the analysis as they both registered missing values for more than one specific year on a particular maternal health indicator. Nevertheless, the present study has some strong points and strengths to offer. The novel ‘Maternal Health Service Coverage Index’ envisaged and constructed in the present study is a pioneer attempt to comprehensively quantify the sub-national coverage of maternal health service in India by including within its ambit 15 indicators spread across each of the three domains of antenatal care, intranatal care and postnatal care. No published study has elucidated the measurement of maternal health service coverage in terms of the broad spectrum of antenatal, intranatal and postnatal care coverage till date in India, though these domains hold prime importance and are widely valued by the reputed international and national organizations [3, 9, 68]. There is wide scope of usage for this unique ‘composite index’ as it provides a concise and quantified information of complex and multifaceted facts representing maternal health service coverage, which makes it easy to communicate and report for the policy purpose [69] at the sub-national level in the Indian setting. This composite summary measure, will reduce the reporting burden and speed up the monitoring of maternal health service coverage at sub-national level in India.The study has further mapped and categorized India into different zones, thereby providing a snapshot of low, medium and high maternal health service coverage states/union territories and regions. This shall help states identify and prioritize the laggard areas (within antenatal, intranatal and postnatal care) to be intervened. Furthermore, the study by considering a nationally representing data published by the Indian government, has facilitated the comparison of the maternal health service coverage performance at the sub-national level across different time points, which has allowed to identify which states/union territories and regions have transitioned from lower to a higher maternal health service coverage category and vice versa.

Measuring and mapping of maternal health service coverage at the sub-national level can have significant policy implications for a developing country like India, which is making rapid strides in healthcare sector transformation. A composite summary measure to reflect the coverage of maternal health services can momentously help India to identify low coverage maternal health service indicators and recognize lagged zones, thereby warranting the concentrated programmatic and clinical efforts to detect, examine and target specific characteristics of a particular state/UT/region that has a significant effect on maternal health service coverage. The accessibility, availability and utilization of quality driven maternal health services are key for survival and wellbeing of both mother and child. A regular longitudinal and extensive monitoring of the performance of states with regard to essential maternal health services shall induce the country towards achieving the SDG target of improved maternal and child health outcomes.