# **2 Son preference, fertility behavior and maternal health outcomes**

## **2.1 Maternal mortality, morbidity, and anemia prevalence in India**

Maternal mortality and morbidity related to childbirth are among the main drivers of excess female mortality during the reproductive years in India (Anderson and Ray, 2010; World Bank, 2011).<sup>6</sup> The WHO estimates that 117,000 maternal deaths occurred in India in 2005 (out of 536,000 worldwide), more than in any other country (WHO, 2007). These figures are considered to underestimate the real burden of maternal mortality due to problems with its standard definition, measurement issues, and lack of adequate data (AbouZahr, 2003; Koblinsky et al., 2012). A maternal death is defined as the ‘death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.’ (WHO, 2010, p. 10). The dominant direct causes of maternal mortality are severe bleeding, hypertensive diseases, and infections, while indirect causes include anemia, HIV/AIDS and malaria (Ronsmans and Graham, 2006). Many direct causes, like severe bleeding, are themselves symptoms of underlying indirect causes such as anemia (Center for Reproductive Rights, 2008). Kahn et al. (2006) conduct a systematic review of the geographical variation in the distribution of the causes of maternal deaths. They find that anemia is the second most common cause after hemorrhage in Asia (causing 12 and 30 percent of maternal deaths, respectively).<sup>7</sup><sup>_,_8</sup> Unsafe abortion is another direct cause, probably resulting in a significant number of deaths, although precise estimates do not exist due to underreporting and misclassification. Despite abortion having been legalized with the 1971 Medical Termination of Pregnancy Act, many Indian women continue to have illegal abortions performed by unqualified practitioners often in unsanitary conditions. Arnold, Kishor, and Roy (2002) argue that there are several reasons why women do not seek safe and legal abortions. These include that they might want to abort for reasons not allowed by the Act (i.e., abortion for sex selection or due to contraceptive failure); they cannot afford the cost of an abortion performed by a registered medical practitioner at a government-approved facility; or because of the unavailability of such facilities. Even though estimates are likely to be imprecise, Kahn et al. (2006) estimate that abortion contributes to about 6 percent of maternal deaths in Asia.

Although not accounted for in standard estimates, maternal mortality ‘implies not only death

> 6The other main cause of excess mortality in the reproductive years (between the ages of 15–44) is death due to injuries, while cardiovascular disease is the most common cause among older women (Anderson and Ray, 2010).

> 7While hemorrhage is found to be the most important cause overall in developing countries, other causes are region-specific, such as sepsis and HIV in Africa, anemia in Asia, and abortion in Latin America.

> 8Other studies provide higher estimates. For example, Gragnolati et al. (2005) and Kalaivani (2009) state that anemia is responsible for almost one quarter and 40 percent of maternal deaths, respectively.

6