It has been more than a decade since the Millennium Development Goals (MDG) were adopted by the United Nations. Fueled by optimism that economic growth in the developing world would translate into reductions in health disparities, the MDGs were designed to focus attention on morbidity and mortality among some of the world's most vulnerable groups. MDG 5, for instance, targeted a two-thirds reduction in the death of mothers living in some of the poorest nations on the globe between 1990 and 2015. While this and other goals have clearly been helpful in mobilizing governments to make healthcare available to all, much remains to be done.
While many nations have made significant progress in reducing maternal death, improvements have been uneven both among countries and populations. Worldwide, more than a thousand women still die each day from pregnancy-related causes [1
]. More than 99% of these deaths occur in the developing world; 87% in sub-Saharan Africa and South Asia-most in just 11 countries. Not surprisingly, given its huge population, India leads the world in total deaths with 63,000 mothers dying each year [2
While annual maternal mortality in India appears staggering at first glance, the world's second most populous country has made significant progress toward attainment of MDG Five [3
]. With a 4.9% rate of decline in the maternal mortality ratio (MMR) between 1990 and 2008, it is one of the few countries achieving reductions close to those required for success in 2015 [4
]. Regionally, India's MMR of 230 per 100,000 population ranks better than Nepal's, Bangladesh's, Pakistan's and Myanmar's with MMRs of 380, 340, 260 and 240 respectively [2
]. As in other parts of the world however, overall gains obscure differences between populations [5
]. Estimates from the Government of India National Family Health Survey (NFHS II, 1998-1999) suggest for instance, that maternal mortality could be as much as 132% higher outside of cities [6
]. In spite of these disparities most areas of India have still seen steady if not spectacular progress in reducing maternal deaths [7
Much of India's current success in rural areas may be attributable to the establishment of the National Rural Health Mission (NRHM). The goal of NRHM was to provide accessible and affordable primary health care to the non-urban poor of India [2
]. This was largely accomplished by revitalizing and staffing more than 22,000 Community Health Centres (CHCs), 4,000 Primary Health Centres (PHCs), and some 150,000 Sub-Centres (SCs) to serve India's rural populations [3
]. Additionally, the government has hired almost a half million Accredited Social Health Activists (ASHAs) to promote health programs, and extended hours of operation for CHCs and PHCs [4
]. While many still complain of glaring deficiencies in NRHM efforts [6
], the clear progress being made in reducing maternal mortality in rural areas speaks loudly for the current health strategy.
Attaining further declines in MMR in India however, is likely to become increasingly difficult as more traditional interventions are exhausted. Some progress appears possible through additional investment in healthcare infrastructure for the rural poor. A recent survey found that nearly 150,000 health centers still do not have a doctor according to India's health ministry [8
]. While activists continue to complain about unevenness of healthcare resources, the NRHM has made significant progress in staffing CHCs and PHCs although there remains a severe shortage of physicians and nurses trained in emergency obstetric care [9
]. As more rural health centers achieve adequate staffing levels however, further reductions in MMR can only come from reaching harder-to-access populations, many of them residing in more isolated rural areas.
Beginning in 1935, the Government of India created a schedule of disadvantaged castes and tribes living in remote areas of the country for additional protection and services [11
]. Labeled by higher Hindu castes as "untouchables" or "Dalits", these groups were often severely impoverished and faced widespread stigma and discrimination [12
]. Scheduled Castes and Scheduled Tribes (SC/ST) had the shortest life expectancy at birth, the lowest rates of female literacy, and the highest infant and maternal mortality rates [11
]. Even today, these SC/ST are among the most economically deprived and marginalized groups in India [14
]. Most are rural, scattered, difficult to reach [15
]. While they make up only 24% of India's total population [8
], a 2008 study by UNICEF concluded that they contribute more than half of the country's maternal mortality [17
]. Karnataka state, where the study was carried out, is one of the top ten states in India for SC/ST [18
The data presented in this paper was collected in a population-based study of mothers in 16 randomly selected rural villages in Mysore Taluk, a subdivision of Mysore District, Karnataka state, between August and September, 2008. All households in each of the selected villages were fully enumerated and data from 1,342 households collected on demographics, caste, antenatal care, and institutional delivery from all mothers with children six or less years of age.