An empirical analysis of maternal health data: A case study of India (https://ieeexplore.ieee.org/document/7877465/references#references) Datasets:  https://www.kaggle.com/rajanand/key-indicators-of-a

An Empirical Analysis of Maternal Health Data: A Case Study of India Shelly Gupta Research Scholar ASET, Amity University Uttar Pradesh, India [email protected] Shailendra Narayan Singh ASET, Amity University Uttar Pradesh, India [email protected] [email protected] Dharminder Kumar CS Department,GJUS&T Hisar, India [email protected] [email protected] Abstract —India is leading all nations in number of maternal deaths. To reduce the national maternal mortality rate the government is doing efforts and has introduced many schemes like JSSK and JSY to create awareness towards the institutional deliveries and to benefit the rural women economically. Despite such programmatic efforts by Indian government the goal to achieve maternal mortality less than 100 per 100,000 live births is far away. To identify the limited success in maternal mortality reduction in India we have compared the maternal health indicators data with some demographic indicators data to rectify the problem. In this paper, we have carried out an empirical data analysis for maternal health in India using secondary data collected from NHRM-HMIS portal. The data is also collected from a statistical publication of Ministry of Health and Family Welfare which consists of most updated data of Annual Health Survey (AHS-4 )and District Level Household Survey (DLHS-4) on maternal health for period 2011-13. To carry out our data analysis we have used Tanagra, a data mining tool to visualize the realistic glimpses of maternal health indicators status in various states of India. In this study we have found that the maternal health status is remarkable in Kerala whereas the situation is totally reverse in Uttar Pradesh and Bihar. This has prompted us to state that if much more effort towards MMR reduction will be put on these states can improve the overall MMR rate of the nation as these states are highly female populated states of the nation.

Index Terms —Maternal Health, Domestic Level Household Survey, Annual Health Survey, Health Management Information System, Maternal Mortality Rate, Ante Natal Care, Infant Mortality Rate, India I. I NTRODUCTION The maternal health is the health during the pregnancy, childbirth, and the postpartum period of a woman [1]. It includes Tetanus Immunization, women immunized with post partum checkups within 2 days after delivery, anemia in women, pregnant women received 3 ANC checkups, TT2/Booster, Hb level less than 11 etc.

For a nation it is important to maintain its maternal health well to reduce its maternal mortality ratio (MMR) which is the count of women over per 100,000 live births in a given year who get died because of complications during their pregnancy and childbirth. MMR data is an important measure to count the quality of a working health system as if new mothers are not thriving well then problems likely exists. In 2005, the WHO has also revealed in its report over world health that poor condition of maternal health is one of the major cause of death among women across the world [2].

In order to reduce the MMR at global level the healthcare features of antenatal, postnatal and family planning are merged with maternal health. By doing so effective results are achieved as the world’s global MMR get reduced from 380 maternal deaths in 1990 to 210 in 2013 over per 100,000 live births [3]. The MMR reduction in last 20 years is quite remarkable but the main cause behind this reduction is the high quality healthcare access in developed countries. The high MMRs still exists in developing countries reason being that in these countries near about half of the deliveries still occurring at homes without any availability of medical facilities for the new mother and new born to handle the complications during birth time[4]. II. MATERNAL HEALTH IN INDIA In India, the government is very attentive towards national prenatal and delivery care. The indan government has started many schemes like Janani Shishu Suraksha Karyakaram (JSSK) supported by UNICEF India and in 2005 Janani Suraksh Yojana (JSY) scheme. The objective of government behind these schemes is to provide free maternity services to the new mother and new born for increasing the poor women’s access to institutional delivery. The result is that the national MMR which was 212 maternal deaths in 2007 on per 100,000 live births get reduced to 178 maternal deaths in 2012 [5]. Despite such programmatic efforts by Indian government there is less success in MMR reduction and because of this current status of national MMR the aim to make it less than 100 per 100,000 live births is out of the way[6,7]. To identify the limited success in maternal mortality reduction in India we compare the maternal health indicators data with some demographic indicators data to rectify the problem.

III. DATA COLLECTION In this paper the empirical data analysis carried out for maternal health in India is based on secondary data collected from NHRM-HMIS portal. The data is also collected from a statistical publication of Ministry of Health and Family Welfare titled “Health and Family Welfare Statistics in 2016 2nd International Conference on Next Generation Computing Technologies (NGCT-2016) Dehradun, India 14-16 October 2016 978-1-5090-3257-0/16/$31.00 ©2016 IEEE 490 India”[8] .This publication presents the most up-to date data on demographic indicators and performance of various programmes in India(2012-13) . This publication provides the data of Annual Health Survey (AHS-4) and District Level Household Survey (DLHS-4). To carry out the empirical data analysis of maternal health in India we have used Tanagra [9], a data mining tool which provides plotting graphs to visualize the realistic glimpses of maternal health indicators status in various states of India.

IV. D ATA ANALYSIS In this paper the empirical data analysis is performed on maternal health data which includes mainly Tetanus Immunization, women immunized with post partum checkups within 2 days after delivery, anemia in women, pregnant women received 3 ANC checkups, TT2/Booster, Hb level less than 11 along with some demographic factors like women literacy rate and mean effective marriage age and female population census data of 2011 of I states and union territories of India. Various scatter plots and line graphs are plotted by using Tanagra and are used to carry out the data analysis based on matching and versus analytical approaches.

1. Effect of Female Literacy on MMR From census 2011 data, shown in figure 1 Uttar Pradesh has the highest female population and West Bengal, Maharashtra and Bihar are other states with high female population. By undertaking the Maternal Mortality rate (2011- 13) with female literacy rate, census 2011 it is clear that the female education plays a great role in Maternal Mortality rate.

The states with higher Female Literacy rate have lower Maternal Mortality Rate. As shown in Figure 2, Kerala is the state with highest Female Literacy rate has the minimal MMR.

Tamil Nadu and Maharashtra are also other states have shown MMR<100 which is quite remarkable in Maharashtra as it is one of the state with high female population. While the results for Uttar Pradesh, Assam, Rajasthan Bihar, Madhya Pradesh and Odisha states are worrying as the MMR >200. Uttar Pradesh and Bihar are the most targeting states as the positive efforts for MMR reduction will target more population at a time. Fig. 1: Female Population Distribution across Indian states and Union Territories, census 2011 Fig. 2: Maternal Mortality Ratio (2011-13) Vs. Female Literacy Rate, Census 2011 2. Effect of Mean age at effective marriage (females) on MMR and IMR In 2006 the mean age at effective marriage in India was 20.5 years and with a minimal increase in its value it get raised to only 21.3 years in 2013. As from figure 3 and 4 it is clear that the higher mean age at effective marriage really plays a great role in reduction of MMR and IMR. Here the states having the Mean age at effective marriage greater than 22 years like Kerala, Tamil Nadu and Punjab have shown less MMR and IMR values as compare to states like Uttar Pradesh, Bihar, Rajasthan Odisha, Assam and Madhya Pradesh which are with mean age at effective marriage less than 22-21 years. According to the census 2011 data the effective marriage age group of females get raised to 21+ years from >18-20 years. It is good news but according to above discussion more efforts are required to make it to 22+ years.

Fig. 3: IMR (Infant Mortality Rate) 2013 Vs. Mean Age at Effective Marriage (females) 2013.

Fig 4: MMR (Maternal Mortality Rate)2011-13 Vs. Mean Age at Effective Marriage(females)2013 2016 2nd International Conference on Next Generation Computing Technologies (NGCT-2016) Dehradun, India 14-16 October 2016 491 3. Status of Ante Natal Care Services (ANC) in India It has been estimated that 25 percent of maternal deaths occur during pregnancy [10]. Antenatal care is the care provides by healthcare professionals to a pregnant woman during her pregnancy period toidentify and treat the health problems that may arise during pregnancy. Antenatal care mainly includes minimal 3 ante-natal care sees, iron prophylaxis, two TT vaccines, finding and treating anaemia in mothers, encouragement of institutional deliveries and Provision of postnatal care. The status of Ante Natal Care of India in its various states and union territories is explained below: 3.1 Atleast 3 Ante Natal Checkups w.r.t. Total ANC Registrations From Figure 5 it is almost clear that the number of women getting at least 3 ante natal checkups with respect to total ANC registration is much less. This situation is a question mark on maternal health awareness in the nation. The states like Andhra Pradesh, west Bengal, Karnataka, Odisha, Tamil Nadu and Kerala have still shown some promising results but the condition of highly female populated states i.e. Uttar Pradesh and Bihar is totally unacceptable. In other states like Haryana, Rajasthan, Jharkhand and Assam also the status of ANC checkups is not remarkable.

Fig. 5: At least 3 ante-natal checkups (2012-13) Vs. Total ANC registr ations 2012-13 3.2 Pregnant women who consumed 100 or more IFA (Iron-Folic Acid) Tablets Vs. No. of women having Hb<11 Figure 6 clearly visualizing that the percentage of pregnant women of consuming IFA tables during her pregnancy is very low as more states come under less than 50%. The health status of females in terms of Hb is good in Kerala, Himachal Pradesh, Mizoram and Andaman &Nicobar Islands as the number of anemic women is less and awareness towards IFA consumption during pregnancy is quite high. But the condition is just reverse in Tamil Nadu, Maharashtra, West Bengal, Rajasthan, Uttar Pradesh, Madhya Pradesh, Haryana and Odisha as the percentage of pregnant women of consuming the IFA tablets during her pregnancy is less than 50% and the number of women having HB<11 is much high. It indicates the threatening condition of Indian women towards her maternal health. Fig. 6: Pregnant women who consumed 100 or more IFA Tablets/Syrup Equivalent Vs. No. of women having Hb<11 3.3 No. of Women Given TT2/Booster Vs. Total ANC Registration The Tetanus Toxoid (TT) vaccine is given to the pregnant women during her pregnancy period in order to prevent the occurrence of tetanus in the new born and new mother . The figure 7 shows that the number of pregnant women who are immunized with TT2/ Booster is quite equivalent to the total number of ANC registrations. For a nation this status of pregnant women who are given TT2/Booster is remarkable and appreciable. But again the status in Uttar Pradesh is questionable as compare to the other states of nation.

Fig. 7: No. of Women Given TT2/Booster Vs. Total ANC Registration 3.4 Total number of Deliveries Vs. Home Deliveries and Institutional Deliveries From the above discussions in Point 1 and 2 we have found that in the states like Uttar Pradesh, West Bengal, Bihar ,Rajasthan and Assam the IMR and MMR are high in comparison to other states due to less female literacy rate and low mean age at effective marriage. The Figures 8 and 9 given below are also showing that the less exposure towards the institutional deliveries is another factor for high IMR and MMR in these states. 2016 2nd International Conference on Next Generation Computing Technologies (NGCT-2016) Dehradun, India 14-16 October 2016 492 Fig. 8: Total No. of Deliveries conducted at Home Vs. Total No. of Deliveries Fig. 9: Total No. of Institutional Deliveries Vs. Total No. of Deliveries 3.5 No. of Women getting Post-Partum Checkups within 2 days after delivery Vs. Total No. of deliveries The postnatal care has a tremendous impact over the maternal and infant mortality rates as most of the post maternal and peri-natal deaths occurs during the first week of delivery. The WHO recommends at least four postnatal checkups in the first 6 weeks for all mothers and new born [11]. Here we have compared the total number of women who are receiving post-partum check up within 48 hours after delivery with the total number of deliveries on the data collected by DLHS-4 of 2012-13 time period. We found that the ratio of taking post partum checkups within 48 hours of delivery is low in Uttar Pradesh, Maharashtra, Bihar, Andhra Pradesh, Gujarat, Tamil Nadu and Madhya Pradesh as compared to other states. It reveals that less awareness towards postnatal care in Uttar Pradesh, Bihar and west Bengal is again a major issue for these states high MMR and IMR. The figure 10 also reveals that the all over status of nation in post natal care is not remarkable and much more effort is required from government to encourage the people towards institutional deliveries where the first postnatal care can be provided easily. Fig. 10: No. of Women getting Post-Partum Checkups within 2 days after delivery Vs. Total No. of deliveries V. C ONCLUSION After going through the empirical data analysis of available data on HMIS portal of DLHS-4/ASH-3 for period 2011-2013 on Indian Maternal health it is clear that the current status of Indian maternal health is not remarkable and need more efforts to improve it. The government is making much effort to improve the level of maternal health in order to reduce the MMR and IMR but some demographic and cultural factors are also affecting the MMR and IMR in India. In our analysis we have found that the Kerala has remarkable maternal health status as the female literacy rate and mean age at effective marriage is high there, as well as awareness towards the ANC and postnatal care is good. Whereas the situation is totally reverse in Uttar Pradesh and Bihar. This prompts us to think that if much more effort towards MMR reduction will be put on these states can improve the overall MMR rate of the nation as these states are highly female populated states of the nation.

R EFERENCES [1] WHO Maternal Health Available from: http://www.who.int/topics/maternal_health/en/ [2] World Health Organization (2005). "World Health Report 2005: make every mother and child count". Geneva: WHO.Available from:

http://www.who.int/whr/2005/whr2005_en.pdf [3] Maternal Health Available from: http://www.unfpa.org/maternal-health [4] UNICEF Maternal Health Available from: http://www.unicef.org/health/index_maternalhealth.html [5] UNICEF India- Maternal Health Available from: http://www.unicef.org/health/index_maternalhealth.html [6] Vora KS, Mavalankar DV, Ramani KV, Upadhyay M, Sharma B, Iyengar S, et al. , “Maternal health situation in India: a case study ”,J Health Popul Nutr.,pp 184 –201, 2009.

[7] Randive B, Diwan V, de Cost a A., “India’s conditional cash Transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality? ”, PLoS One.2013.

[8] Health and Family Welfare statistics in India 2015 Available from:

https://nrhm-mis.nic.in/SitePages/Pub-FW-Statistics2015.aspx [9] TANAGRA: A Data mining software Available from: http://eric.univ- lyon2.fr/~ricco/tanagra/en/tanagra.html [10] Antenatal Care Available from:

http://www.who.int/pmnch/media/publications/aonsectionIII_2.pdf [11] Postnatal Care for Mothers and Newborns Highlights from the World Health Organization 2013 Guidelines Available from:

http://www.who.int/maternal_child_adolescent/publications/WHO- MCA-PNC-2014-Briefer_A4.pdf 2016 2nd International Conference on Next Generation Computing Technologies (NGCT-2016) Dehradun, India 14-16 October 2016 493