The article on high-risk pregnancies in The Hindu on February 17 astutely drew public attention to a matter of great concern to the obstetrics and gynaecology community, but often overlooked by the rest of the country. India has great strides in decreasing maternal mortality — from an MMR of 130/100,000 live births in 2016-2018 to a MMR of 97/100,000 in 2018-2020 — by ensuring an increase in institutionalised deliveries and antenatal care, and improving women’s access to reproductive healthcare services. However, India still has a long way to go. While we celebrate our achievements, we must confront the challenges that persist, ensuring that every pregnancy is safe, and every woman is assured of the best possible care.

Acknowledging that India is now the most populous country in the world, most States have begun to see an optimal total fertility rate to ensure a more stable population growth. But pregnancy is not always easy to go through and abound with risk factors. The study referenced in the mentioned piece, illustrates that on average across India 49.1% pregnancies are high-risk. Short birth spacing — less than 18 months between two pregnancies — tops the list making up for 31% of the contributing risk factors, followed by previous adverse outcomes at 19%. These risks are disproportionately higher among women with limited or no education. In a telling comment, the researchers noted in the article, “nearly half of Indian women were not using contraception to delay their next pregnancy”. This is a stark reminder of a critical gap in our healthcare and educational systems: the underutilisation of continuous, consistent, effective, modern contraception. Women and their partners need more information about and access to modern contraceptive products to help them choose what’s best for their bodies.

Pregnancy is an intense physiological experience. A gap of two-three years between pregnancies is recommended to give a woman enough time to recover, regain her health, strength, and nourishment before she is ready to give birth to and take care of another child. Beyond the health benefits, when women exercise autonomy and agency over their bodies and reproductive decisions, they are not merely making personal choices; they are stepping into a realm of empowerment that has ripple effects beyond themselves. The economic benefits for example of such empowerment are profound.

Contraception or family planning helps ensure that women and men can choose if, and when they want to have children. The Indian family planning programme has for many years effectively offered a basket of choices for modern methods — and has reached many milestones in reducing what is known as the unmet need across most parts of the country. In the public sector, the current basket includes condoms, combined oral contraceptive pills, emergency contraceptive pills, intrauterine contraceptive device (IUCD), an injectable contraceptive (medroxyprogesterone acetate or MPA) and contraceptive tablet centchroman (Chhaya). Additionally, two new methods — a subdermal contraceptive implant (HI) and the subcutaneous injectable contraceptive (DMPA-SC) — have been introduced in the public health programmes of a few States (these two methods though aren’t available in the private sector just yet). They are easy to administer and can prevent pregnancy for three years (subcutaneous implants) and three-four months (DMPA-SC) at a time thus making them convenient and discreet choices. All these methods are safe, high-quality, and reversible.

But evidence suggests that the most common modern methods still in use in the country are female sterilisation (which is permanent), and male condoms (which are often incorrectly used — thus reducing their effectiveness — and women may not always have the choice to use them).

Awareness and evidence-based information are key to encouraging people to choose the best method for themselves. But a lack of information and understanding among the end users, limited engagement with communities can mean that people do not feel comfortable and empowered to make these choices. Misconceptions, negative experiences, misinformation, and taboos, often fuel hesitancy. Better counselling and stronger communication are imperative.

And that is where medical providers come in. As trusted credible sources of information, it is incumbent on medical providers to go the extra mile to ensure that people have accurate information that can help them exercise their right to choose. Contraception and family planning are no longer just about population; they are an essential part of a woman’s freedom, her agency, her bodily autonomy — her empowerment. When we make sure our women are empowered, we can unleash and realise the full potential of Nari Shakti.

(Jaydeep Tank is the president of The Federation of Obstetric and Gynaecological Societies of India (FOGSI))

Representational file image.
| Photo Credit: AFP

A study that analysed the data of nearly 24,000 pregnant women in India has found the prevalence of high-risk pregnancies to be high at 49.4%. About 33% of pregnant women had a single high-risk factor, while 16% had multiple high-risk factors. Northeastern States of Meghalaya (67.8%), Manipur (66.7%) and Mizoram (62.5%) and the southern State of Telangana (60.3%) had the highest prevalence of high-risk factors in India, while Sikkim (33.3%), Odisha (37.3%) and Chhattisgarh (38.1%) had the lowest prevalence of high-risk pregnancies. With 33%, women in Meghalaya had the highest frequency of multiple high-risk factors followed by Manipur, Andhra Pradesh and Telangana, as per a study published recently in the Journal of Global Health by researchers from the ICMR’s National Institute for Research in Reproductive and Child Health (NIRRCH) in Mumbai.

The study used the nationally representative cross-sectional household survey data of the National Family Health Survey-5 (2019-2021). The researchers used the unit-level data from the Demographic Health Surveys (DHS) programme. Data from around 28,400 currently pregnant women aged 15-49 years were extracted. Of these, 23,853 women who were pregnant at the time of the survey were included in the analyses. While 12,183 (50.6%) of pregnant women had no high-risk factors, 11,670 (49.4%) of pregnant women had one or more high-risk factors and were categorised as high-risk pregnancies.

The study found that pregnant women from vulnerable populations such as poor women and those who had no education had the possibility of having one or more risk factors for pregnancy. The leading high-risk factors were: short-birth spacing (the time interval between the last birth to the time of current conception being less than 18 months), adverse birth outcomes such as miscarriage, abortion, or stillbirth, and finally women whose most recent delivery was a caesarean section. The risk factors that were considered for the study were maternal risks, lifestyle risks, medical risks, current health risks, and previous birth outcome risks. Maternal risk factors included the age of the mother — adolescent women aged 15 to 17 years and women older than 35 years — pregnant women who are short (height below 140 cm), and have a higher body mass index of over 30. Additionally, the gestational weight gains up to 7-11 kg for overweight women and 5-9 kg for obese women were considered high-risk pregnancies.

‘Risk factors’

Lifestyle risk factors included tobacco use and alcohol consumption, while previous birth outcome risks included pregnant women with more than five children, women with short birth spacing and long birth intervals of over 59 months. Also, women with a history of preterm deliveries, miscarriages, abortions, or stillbirths were included under the category of previous birth outcome risk factor.

Short birth spacing of less than 18 months between previous birth and current conception was observed in 31% of pregnant women, followed by 19.5% of women with a history of adverse birth outcomes — either miscarriage, abortion, or stillbirth. Women who had recently delivered through caesarean sections were found in 16.4%. Other high-risk factors were women having longer spacing (15.8%), history of preterm delivery (14.1%) and comorbidities (6.4%).

Risk factor arising from adolescent pregnancies was highest in Tripura (10.3%), while advanced maternal age of over 35 years risk factor was most seen in Ladakh (14.3%), short stature (height below 140 cm) was highest in Puducherry (4.8%), and BMI over 30 was seen in Goa (17.4%). Women with more than

Women with more than five children (higher birth order) were seen in Meghalaya (10.7%), whereas short birth spacing of less than 18 months was highest in Andhra Pradesh (48.1%), and caesarean delivery was highest in Ladakh and Puducherry (50% each). Women in Chandigarh had the highest adverse birth outcomes (40%) as well as preterm births (37.5%).

“The short birth spacing was the primary factor contributing to the high prevalence of high-risk pregnancies across the country. The major problem of short birth spacing was that half of the Indian women were not using contraception to delay their next pregnancy,” the authors write. “The under five-mortality rate for shorter birth intervals was reported to be twice as high as the rate for birth intervals of three or more years.”

The authors suggest that policies and programmes and creating public awareness and education of women are needed to address the short interval between two successive pregnancies.

According to the study, high-risk factors were more commonly seen during the third trimester (51%) than in the first (48.8%) and second trimester (48.6%).

The proportion of multiple high risks was higher among women with no educational category (22.5%) compared with educated women.