Pregnant, undiagnosed, and at risk

Despite progress in reducing maternal deaths, too many Indian women still miss routine pregnancy tests. Lakshmi Sethuraman & Ritika Ramasuri offer a closer look at the silent barriers to diagnostics in maternal care

Lakshmi Sethuraman & Ritika Ramasuri

Across many parts of rural India, accessing antenatal care remains a challenge, not because women don’t value it, but because the system often doesn’t meet them halfway. Clinics can be far, daily household work leaves little time, and health centres aren’t always open or staffed with providers women feel comfortable with. Even essential care, like antenatal checkups, gets missed when services don’t respond to the realities of women’s lives.

This is a widespread experience. The most recent National Family Health Survey (NFHS-5, 2019–21) found that only 58.5% of pregnant women in India received the recommended four or more antenatal care (ANC) visits — the basic minimum outlined by the National Health Mission. In states like Nagaland, Bihar, Assam, and Uttar Pradesh, the numbers are far lower. In Nagaland, for example, just 20.7% of women received adequate ANC.

This local reality reflects a growing global concern. On World Health Day 2025, a joint UN report — Trends in Maternal Mortality — revealed that while global maternal deaths dropped by 40% between 2000 and 2023, progress has stalled since 2016. In 2023 alone, an estimated 2,60,000 women died from pregnancy or childbirth-related complications — roughly one every two minutes. The report warns that declining international aid and chronic underinvestment in essential services are threatening to reverse hard-won gains, particularly in low and middle-income countries. And as systems grow more fragile, basic services like antenatal diagnostics are often the first to disappear. 

MMR concerning

India’s Maternal Mortality Rate (MMR) has improved significantly — from 384 deaths per 1,00,000 live births in 2000 to 97 in 2018–20. But this progress conceals deep inequities. States such as Assam, Uttar Pradesh, and Madhya Pradesh continue to report MMRs over 150. And the national average still exceeds the Sustainable Development Goal (SDG) 3 target of 70 deaths per 1,00,000 live births by 2030. What’s striking is how preventable many of these deaths are.

Conditions like anaemia, hypertensive disorders, and infections — the leading causes of maternal mortality— can be identified through simple, routine diagnostic tests. Yet these are often unavailable, underused, or avoided altogether. 

Diagnostics are not a luxury

Antenatal diagnostics are the first line of defence. They include haemoglobin tests to detect anaemia, urine tests for protein, glucose checks for gestational diabetes, and blood pressure monitoring to detect hypertensive disorders. They’re simple, but when missing, the consequences can be fatal. According to the Lancet Commission on Diagnostics (2021), nearly 47% of the global population lacks access to basic diagnostic services. This gap ranges from 35% to 62% in low and middle-income countries. Narrowing that gap to just 10% could save over a million lives annually. Yet diagnostic tools often fail to reach the women who need them most, especially those in poor, remote, or marginalised communities. The problem is partly structural — limited availability. But it’s also deeply social.

Why do women avoid tests?

In some communities, blood tests are mistrusted, with fears that samples might be misused. In others, the lack of privacy or the presence of male technicians makes women uncomfortable. There’s also a broader mistrust of health systems.

Even when devices are available, uptake is shaped by everyday realities — gender, caste, income, education, and power. That’s why diagnostic tools must be designed with last-mile challenges in mind. This matters even more when tests are intimate or invasive.

A recent report, Making Antenatal Diagnostics Work, by the Sattva Knowledge Institute and Jhpiego India, shares first-hand insights from 17 diagnostic innovators and 12 ecosystem stakeholders. It highlights how many promising tools, built for low-resource settings, fail to scale beyond pilot projects. 

Don’t forget the frontline

India’s maternal health system rests heavily on frontline workers — ASHAs, ANMs, and Anganwadi workers. They are overburdened, underpaid, and stretched thin across immunisation drives, nutrition programmes, and administrative duties.

If diagnostic devices are too heavy, fragile, or complex, they won’t be used. Portability, rechargeability, and durability are not extras — they are essential. Equally vital is training.

Many devices fail not because of poor design, but due to a lack of support for frontline workers to use them effectively.

Diagnostics must also be paired with community engagement.

Platforms like Village Health Sanitation and Nutrition Days (VHSNDs) can build trust, normalise testing, and increase uptake, especially when they involve local women and community health volunteers.

From innovation to integration

India is not short on innovation. Many of the most promising antenatal diagnostic tools have been developed here. But few make it into national or state health systems. To scale, diagnostics must be integrated into public programmes. This means coordination between departments, updates to treatment protocols, and support for adoption.

Too often, innovations get stuck in “pilot mode.” Governments must create space for innovation, not just in labs, but within public health systems.

Private investors have a role to play, too. Many diagnostic innovators are stuck in a cycle of grant funding, unable to raise capital for clinical validation or commercial rollout. Med-tech may not offer fast returns, but it saves lives.

We often imagine life-saving care in terms of high-tech surgeries or world-class hospitals. But sometimes, the difference between life and death is a simple test — a haemoglobin reading, a urine strip, a blood pressure check. Done early. Delivered with care. Trusted by the woman receiving it.

Diagnostics are not a luxury. They are the first step in care. They must be accessible, dignified, and designed for the women who need them most. Because when a woman can be tested without fear, diagnosed without delay, and treated without hesitation — that’s when a maternal health system truly begins to work.

(Lakshmi Sethuraman leads large-scale health initiatives across maternal, mental, and digital health, specialising in strategic advisory, programme design, and sustainable social business models while Ritika Ramasuri is a consultant researcher and has worked on nutrition for children under 5, supply chain of essential medicines, climate change and health, digital public goods for health planning, and diagnostic innovations for antenatal care.)