Determinants of Maternal Mortality: An Empirical Study of Indian States Based on the Random Effect Model Analysis

been uneven. 3 To achieve these objectives, the government set up National Rural Health Mission (NRHM) in 2005, with the goal of providing good healthcare in the rural area and promoting high-quality infrastructure, particularly in backward areas, with a focus on improving infants, children, and maternal health. One of NRHM’s flagship programmes, Janani Su-raksha Yojana (JSY) has introduced in 2005. The im-ABSTRACT Background: Healthcare for mothers and children is a significant indicator of a country's well-being. India is one of the nations that were experiencing a rather slow improvement in maternal and child health. Aims: The objective of this study is to analyse the changes in health infrastructure, government health expenditure, antenatal care, postnatal care, institutional delivery, Maternal Mortality Ratio (MMR) and the determinants of MMR in India. Methodology: The study is based on secondary data. It employs an Average Increasing Rate (AIR) and Average Reduction Rate (ARR), as well as a panel data random effect model. Results: Empirical results say MMR has a statistically significant inverse relationship with female literacy, Per capita Net State Domestic Product (PNSDP), and institutional delivery. The study concludes that after the introduction of NRHM and its constituent elements like JSY and JSSK, government expenditure on health, health infrastructure, the percentage of antenatal care, post-natal care, and institutional delivery increased in most of the Indian states, thus helping to increase the pace of the reduction of MMR. However, state performance varies greatly. Conclusions: Policy alone will not provide the desired results; it is also critical to focus on education, particularly female literacy, and economic empowerment.


INTRODUCTION
Mother and child healthcare is an important indication of a country's well-being. India is one of the countries that has seen a modest improvement in maternal and child health. During the early 21st century, the country was victim to high rates of maternal deaths, around 254 per hundred thousand live births (SRS-2004-06), larger than the world average. 1 In 2017, there were almost 810 preventable deaths of women every day connected to pregnancy and delivery. 2 Millennium Development Goal number five intended to lower the MMR by three-quarters from 1990 to 2015. India has made great progress toward the Millennium Development Goals, with several targets being met ahead of the 2015 deadline, but development has been uneven. 3 To achieve these objectives, the government set up National Rural Health Mission (NRHM) in 2005, with the goal of providing good healthcare in the rural area and promoting high-quality infrastructure, particularly in backward areas, with a focus on improving infants, children, and maternal health. pact of JSY, the largest Conditional Cash Transfer Scheme (CCT) was impressive. It brought the marginalised rural pregnant women to public health institutions for antenatal care and delivery. Another component of NRHM, ASHA, performed the duty of IEC (Information, Education, and Communication). The result was highly impressive. Institutional delivery increased in most of the states, especially in backward states like UP, Bihar, MP, Rajasthan, Odisha, etc. and it directly worked as a catalyst for the reduction of mortality of mother and child. 4 But it was limited to a certain category population only. So, its impact was also limited, especially among urban and high-profile populations. Moreover, one of the causes of lower institutional deliveries was the large out-of-pocket expenditure in private hospitals and the lack of infrastructure and human resources in government hospitals. NRHM, to some extent, was helpful to increase infrastructure and manpower in government hospitals but did not touch on the problem of high out-of-pocket expenditure. By realising this, the government of India introduced Janani Shishu Suraksha Karyakram (JSSK) for the elimination of out-of-pocket expenditure in public health institutions after five years of NRHM. Therefore, it is important to empirically analyse the factors that influence Maternal Mortality 15 years after the introduction of NRHM.

OBJECTIVES
This research covers many goals related to the delivery of healthcare services to pregnant women. The paper simply attempted to analyse the average improvement / average reduction rate of health inputs (like Per capita Government Health Expenditure, Average Population Covered by SCs, PHCs, and CHCs), health outcomes (like Antenatal Care, Institutional Delivery in Government Hospitals, Out of Pocket Expenses during Delivery in Government Facilities, Post-Natal Care) and health impacts (like MMR) between 2010-11 and 2019-20. This study also aimed to explain the determinants of maternal mortality in India after the implementation of NRHM.

METHODOLOGY
This study is based on secondary data. For comparison, mostly 2010-11 and 2019-20 data are used. The data was collected from government sources like Sample Registration System, Health Management Information System (HMIS), National Family Health Survey (NFHS-4 and NFHS-5), Rural Health Statistics (RHS), and Annual Health Survey (AHS). This study has the following methodological divisions: First, an Average Increasing Rate (AIR) or Average Reduction Rate (ARR) is calculated for all the health indicators mentioned above, except for the average population covered by SCs, PHCs, and CHCs. In that indicator case, a government public health standard norm is used for the analysis of the improvement.
Second, previous studies on the impact of JSSK on mother and child healthcare were analysed and interpreted.
Third, to empirically analyse, the factors determining the reduction of MMR, the random effect model is used. The data for Indian states from 2007-08 to 2019-20 (13 years) were used for empirical analysis.
The states in which the number of pregnant women registered in a year is two lakh or more were included in the data set. MMR data for Jammu and Kashmir is not available so it is excluded from the data set. There are therefore 17 states.
The model is: Where i -is entity (17 states), t -is time (2007 to 2020-13 years), β -is the intercept, Y -is the dependent variable (MMR here), X -are the independent variables or the variable of interests, Zare other explanatory variables like Percentage of Female literacy and per capita net state domestic product, β -is the coefficient for independent and other explanatory variables, υ -is the individual impact of i th entity (respective states here), and not measurable, and ε -is the error term, represents unobserved elements that change over time and impact Yit.
To identify whether there is a correlation between υ and X , ε and υ , Hausman test is applied, which accepted the null hypothesis. The Breusch and Pagan Lagrangian multiplier test confirms the random effect and evidence of significant differences across states.

RESULTS
Improvements in Government health expenditure: In view of the constant growth in healthcare expendi-tures in most industrialised countries, policymakers are interested in the relationship between healthcare expenditure and health outcomes. 5 "In an attempt to address data heterogeneity difficulties, Cremieux et al looked at the relation between spending and health outcomes in ten Canadian provinces from 1978 to 1992. Lower healthcare spending was connected with a significant rise in new-born mortality and a reduction in life expectancy". 6 Across Indian states, per capita government health care expenditure has inversely related on infant and child mortality, malaria cases, and a positive impact on life expectancy and immunisation coverage, whereas this impact is rather small in the High-Focus States. 7 In response to the achievement of the Millennium Development Goals, the government implemented the NRHM and other programmes, which resulted in an increase in public health expenditure across states over time.
Over the study period, all states' per capita government health spending increased (Table 1). In Himachal Pradesh, Kerala, and Uttarakhand, the difference is greater, whereas, in Bihar, Jharkhand, UP MP, and Assam, it is smaller. Haryana, Kerala, and Gujarat have higher average improvement rates, while Uttarakhand, Assam, and J&K have lower average improvement rates (Table 3). Health infrastructure and health outcomes: Many national and international research has shown that there is a substantial link between health infrastructure and health outcomes. Improved access to health services, trained health workers, better drug usage, and increased funding for health in India can all help to improve health outcomes. 8 A study discovered a favourable link between primary health infrastructure and curative and preventative health outcomes. 9 The availability of hospitals, staff in health centres, and the number of hospital beds might all contribute to a lower IMR and longer life expectancy. 10 According to a study improving the quality of health infrastructure facilities can help women have fewer difficulties throughout their pregnancies. 11 The healthcare infrastructure in rural areas has been made as a three-level system based on demographic norms. SCs can serve a maximum of five thousand people in plain areas and three thousand in hilly areas, whereas PHCs can serve a maximum of thirty thousand people in plain areas and twenty thousand in mountainous areas, and CHCs can serve a maximum of 1,20,000 people in plain areas and 80,000 in hilly areas. In this study, we're looking at the average population served by SCs, PHCs, and CHCs as a health infrastructure variable to determine if there's a link between health outcomes and infrastructure.  It encourages institutional births, lower maternal mortality, and a higher likelihood of infant survival. Based on the efficacy of the healthcare system, the World Health Organization advises at least four prenatal care visits. In India, the percentage of Antenatal check-ups (three or more) has risen from 70.9 per cent to 79.5 per cent ( Table 2). The highest positive change is marked by J&K, Madhya Pradesh, and Bihar whereas the lowest is marked by UP, Uttarakhand, Punjab, and Rajasthan with negative changes.
Institutional Birth in Public Facility: Skilled delivery attendance is a key metric for tracking progress toward Millennium Development Goal 5. NRHM and its components, especially Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Yoajana (JSSK) encourage institutional delivery to reduce maternal and infant deaths. JSSK was established in India in 2011 to provide free institutional delivery to pregnant women. Due to the implementation of these programmes, institutional delivery in India has increased many folds. 12 Institutional delivery improved because of the JSSK initiative. 13 JSSK benefited women who used public services, however, medications, consumables, and transportation added to out-ofpocket expenses. 14 Institutional delivery has grown in almost all states throughout this time span. Karnataka has the most unfavourable change (-10 percent). Kerala and Himachal Pradesh have the highest levels of institutional delivery in absolute terms ( Table 2 & 3). ID at a public facility is lower in high-profile states.
Out-of-pocket expenditure in public facilities: Out-of-Pocket Expenses (OoPE), which accounts for more than 60 per cent of overall health spending in India, is the primary source of funding (Indian Institute of Public Health). Many services are focused on maternal health since they are the most vulnerable and majority group (2/3rd) of the population, and most diseases and deaths among them are avoidable. 15 To eliminate OoPE in mother and child healthcare, the government launched JSSK in 2011. The scheme is open to all. According to NFHS-5 data (  (Table 3).
Postnatal Care: Promoting prenatal care and competent birth attendance is obviously insufficient to enhance the health of mothers and children. "According to the WHO's postnatal care recommendations, all mothers and their new-borns should get the essential routine postpartum care, with special focus given to low birth weight and early diagnosis, referral, or management of emergency conditions. Postna-tal visits between 6 and 12 hours after birth, as well as follow-up visits between 3 and 6 days, 6 weeks, and 6 months, are all recommended". We can detect large disparities in performance among Indian states. This observation are important because the safe motherhood programmes was introduced a long way back. In India, most maternal mortality is still linked to variables including nutrition, poverty, and social marginalisation, on which interventions have had little or no influence. 16 According to their findings, economic growth alone can cause changes in MMR in India. They observed that MMR and PNSDP, TFR, and SC/ST populations had a strong relationship. Another study re-examines the causes of maternal mortality in India, using data from the SRS 2001-03, and concludes that direct obstetric factors account for over 80 per cent of maternal fatalities in India. 17 As a result, policymakers may employ these regions to achieve the MMR objective more effectively.   The random effect model's findings (Table 4) indicate that majority of the variables we considered have a negative and significant association with MMR. Female literacy (p<.01), PNSDPatCP (p<.01), TnFRUs (p<.05) and IDtoTRepDel (p<.05) all are negatively associated with MMR, this means if female literacy increases by one unit MMR will decrease by 9.44 units. Similarly, if per capita state domestic product increase by one unit the MMR will come down by 0.1676 units. If the total number of first referral units increases by one unit MMR will decline by 0.1245 units. If institutional delivery increases by one unit MMR will decline by 0.387 units. One of the flagship programmes ASHA Workers has no significant impact on reducing MMR according to this empirical result. Similarly, the result says if antenatal care increases MMR also will increase (highly significant). It is quite contrary to what has been seen and recommended which is a serious issue to be further studied whether it is because of the lack of quality of antenatal care provided to pregnant women, especially in rural areas or because of any other reason. Using panel Fixed Effects models, R K Mohanty, and D K Behera (2020) of the National Institute of Public Finance and Policy in New Delhi investigated the effects of public health spending on selected health outcomes such as life expectancy, infant and child mortality rates, malaria, and immunisation across 28 Indian states from 2005 to 2016. 7 "The empirical findings reveal that per capita health-care spending has a positive and statistically significant influence on life expectancy and immunisation, but a negative impact on new-born mortality, child mortality, and malaria cases. Per capita income, like public health investment, has a negative influence on new-born and child mortality and malaria, while having a positive impact on boosting life expectancy across States." Our study also reiterates that a unit increase in state NRHM expenditure leads to a decrease in the IMR by 0.1196 units (p<.1).
As far as the average population covered by health facilities are concerned, the number of SCs rose by 6 per cent, the number of PHCs increased by 9 per cent, and the number of CHCs expanded by 55 per cent between 2005 and 2016. The issue with this expansion is that the number of SCs, which serve as patients' initial point of contact, has not expanded in proportion to the population, which has increased by 15.7 per cent during this time. As a result, the strain on the PHC and the CHC has increased. With a shortage of approximately 81 per cent of experts, CHCs are already in a dire situation.
"Since 2005, the government has succeeded in providing buildings for SCs, PHCs, and CHCs, which have risen to 65 per cent, 45 per cent, and 91 per cent, respectively, under the name of infrastructure. However, these buildings lack basic facilities and resources for delivering healthcare. According to the Rural Health Statistics 2016, 71 per cent of PHCs have labour rooms, although the study does not specify the equipment or functional status of these labour rooms in accordance with Indian Public Health Standard criteria. 19 There is an 83 per cent shortage of surgeons and 76 per cent shortage of obstetricians and gynaecologists in CHCs nationwide. India's healthcare spending remains the lowest among BRICS countries. Such statistics mean that specialised healthcare treatment in rural India is difficult, which has driven rising numbers of people to costlier private healthcare. In rural India, 58 per cent of hospitalised treatment was carried out in private hospitals, while in urban India the figure was 68 per cent, according to the Key Indicators of Social Consumption on Health 2014 survey carried out by National Sample Survey Office". This is the reason why in our study empirical analysis shows a positive and significant relationship (p<.1) between Out-of-Pocket expenditure and IMR in which most facilities are still not available in public health facilities so pregnant women have to depend on private facilities to safeguard their pregnancy and childbirth.
The percentage of Antenatal Care increased in most of the states except Goa, Mizoram, Nagaland, Odisha, Punjab, Rajasthan, Sikkim Uttarakhand and UP. Institutional delivery in public health institutions has increased in all states except Goa, Karnataka, and Rajasthan. The twin components of NRHM, JSY and JSSK have a proven track record of boosting institutional births and obstetric patient bookings (thereby improving antenatal care). They have also raised the number of NICU admissions at level III government centres, owing to greater use of expensive advanced modalities across all socioeconomic groups. 20 Evidence from rural Haryana, North India, indicated that when the JSSK plan was implemented, the number of deliveries at the primary care level increased by more than double, despite no major changes in human resources or facilities at the study institution. Since its inception in 2006, the JSY programme has helped to develop demand in the community for institutional delivery. Services were given under JSSK that contributed to a further rise in institutional de-livery in the study area's population that had previously been primed by the JSY programme.
Out of Pocket Expenditure still exists in public health institutions during delivery. In Kerala, Goa, Gujarat, Maharashtra, Meghalaya, Nagaland, Telangana, and West Bengal OoPE decreased. Even after the introduction JSSK in most of the states, there is no sign of elimination of OoPE rather it is increased while comparing with the previous NFHS-4 data. Although OoPE decreased slightly after the implementation of JSSK, there was no discernible difference in catastrophic health expenses between the pre-JSSK (21.2 per cent) and post-JSSK (15.6 per cent) periods. 21 According to another research, 83.5 per cent of the sample group who received JSSK benefits had OoPE. The computed average expenditure was INR 4289. 22 The median OOPE was INR 1100. Beneficiaries were still facing substantial health expenditures, according to a survey done in regions of Delhi. Diagnostics accounted for the largest percentage of spending, which may be ascribed to infrastructure bottlenecks; pharmaceuticals accounted for the second-largest share of spending, which can be linked to a lack of availability of drugs. 23 The JSSK initiative in Chhattisgarh has not been able to achieve its goal of decreasing the expenditure on pregnant women in public health facilities. Medicine, food, and transportation accounted for many of the costs. Due to a lack of human resources, poor health facility infrastructure, and irregular and insufficient pharmaceutical supplies, recipients are forced to pay exorbitant fees during institutional delivery. This demonstrates that government spending on the plan is insufficient, which should be addressed by wise resource allocation to increase JSSK efficacy. 24 More than 70 per cent of pregnant women in West Bengal's Bankura area are aware of the programme, yet only 20 per cent of them use it. Medicine, transportation, and diagnostics are the areas of expense. According to this study, JSSK failed to meet its intended purpose of providing cost-free services to pregnant women and unwell babies due to shortcomings in its implementation, mostly at facility levels. 25 Post-Partum check-ups (48 hours to 14 days) have been increased in all states except Madhya Pradesh, Rajasthan, Tamilnadu and Mizoram. Maternal Mortality decreased in all states between 2010-11 and 2019-20. In India, the combined effect of facility births and postnatal examinations is connected to a much lower risk of new-born death than merely delivering the baby in a facility. If these associations are causal, facility delivery combined with postnatal examinations in India might prevent roughly a third of all new-born deaths. 26 Overall socio-economic development, with a focus on women's empowerment and education, can improve the usage of maternal healthcare. 27 According to research done in eastern India, despite several government programmes, excellent socioeconomic level, the mother's education, and the existence of health-related disorders in the mother or the infant, post-natal care remains unac-ceptably low, owing to a lack of effective postnatal care counselling. Staff sensitization, standard policy, and mother-centred counselling are still needed to improve postnatal care services. 28 States not achieved MMR target in compliance with MDG-5 (109 or less by 2015) are Bihar, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Assam, Chhattisgarh, Jharkhand, and Uttarakhand. There exist interstate variations in the performance of maternal healthcare mainly because of demographic, educational, social, cultural, geographical, and economic factors. Even though India fell short of the MDG target, the country has made significant progress. This is due to four significant variables. First, with the implementation of the NRHM, India has made a deliberate effort to enhance access to high-quality maternal health services. Since then, institutional delivery has grown from 38 per cent to 79 per cent. Second, state-subsidised demand-side financing programmes like the Janani Shishu Suraksha Karyakram -which provides free transportation and no-cost delivery, including C-section, to all pregnant women giving birth in public health institutions -have largely eliminated the traditional urban-rural divide in institutional births. In all, 75 per cent of rural births are currently based on skilled attendance, compared to 89 per cent of metropolitan births. Third, India has placed a high priority on addressing the socioeconomic determinants of maternal health. India's women are more literate than ever before, with 68 per cent able to read and write. They are also marrying later age, with only 27 per cent of them marrying before the age of 18. Finally, the government has made significant efforts to promote beneficial collaboration between public and private healthcare providers. Women now have access to prenatal checkups, obstetric gynaecologists, and the ability to track high-risk pregnancies attributable to campaigns like the Pradhan Mantri Surakshit Matritva Abhiyan. 29

LIMITATIONS
There is a dearth of long-term, continuous, and comprehensive data linked to several significant variables of interest in this study, which makes it difficult to use dynamic models like the ARDL-ECM. This could affect how accurate the outcomes are. The more observations in the data set, the more accurate will be the study.

CONCLUSION
To conclude we can say that NRHM and its constituent elements like JSY and JSSK policy articulations and information distribution are present in all states, resulting in an increased understanding of pregnant women's and ill new born's entitlements. For JSY/JSSK registered pregnant women, almost all entitlements are being received, although out-of-pocket expenses for medicines, diagnostics, and referral transportation for pick-up and drop-off remain (13th