Maternal mortality and India’s multifold challenges

The Sustainable Development Goal (SDG) 3.1 set by the United Nations is aimed at reducing the maternal mortality rate (MMR) to 70 per lakh live births by 2030. India has achieved significant progress in improving maternal health outcomes, reflected in a steady decline in MMR and expanded access to quality maternal healthcare services. Through a robust framework of national programmes such as the National Health Mission (NHM), Reproductive, Maternal, Newborn, Child, and Adolescent Health plus Nutrition (RMNCHA+N) strategy, and Ayushman Bharat, India has demonstrated its commitment to achieving the target.

Maternal health is an important aspect for the development of any country in terms of increasing equity and reducing poverty. The survival and wellbeing of mothers is not only important, but is also central to solving larger, broader, economic, social, and developmental challenges. Massive and strategic investments have been made under the NHM for improvement of maternal health. However, one of the key indicators of maternal mortality is the MMR which is defined as the number of maternal deaths during a given time per 100,000 live births during the same time.

A study of MMR in India during the pre-NRHM (now NHM) and post-NRHM periods shows a significant reduction in the rates. As per the Sample Registration Survey (SRS) of India, MMR was 398 in 1997-98, it decreased to 212 in 2007-09 and further declined to 97 by 2018-20. The decline can be attributed to effective implementation of various health programmes and schemes under NHM. A similar decline could be seen across all the major states for the same periods. But many states have continued to report high MMR – these include Assam (195), Madhya Pradesh (173), Rajasthan (167), Uttar Pradesh (103), Haryana (110), Punjab (105), and West Bengal (103).

No doubt, under the NHM, there has been a substantial improvement in MMR. However, regional imbalances in terms of socio-economic development have stopped the progress of many states in efforts to reach a two-digit rate. The SRS figures show that the southern states – Kerala (19), Telangana (43), Andhra Pradesh (45), Tamil Nadu (54), and Karnataka (69) – have done significantly better. These states have reached the SDG goal well in advance. In the central region, except Jharkhand, no state has recorded a two-digit MMR.

The national health programmes and plans have evidently led to positive maternal health outcomes. But now, special attention needs to be given to the central and north-eastern states to ensure an even national spread of the initiatives.

Navigating barriers

Maternal mortality remains a significant public health challenge due to multiple medical, infrastructural, socio-economic, and systemic factors. Despite efforts to enhance maternal healthcare services, several critical issues continue to contribute to maternal deaths.

1. High-risk pregnancies: Many maternal deaths occur due to high-risk conditions such as gestational diabetes, hypertension, anemia, and pre-eclampsia. These complications require timely medical intervention, which is often delayed due to a lack of awareness, inadequate healthcare facilities, or financial constraints.

2. Limited access to healthcare facilities in vulnerable areas: Pregnant women in rural, remote, and hard-to-reach areas face significant challenges in accessing maternal healthcare. Poor road infrastructure and inadequate transportation services exacerbate delays in reaching healthcare facilities.

3. Out-of-pocket expenditure despite government schemes: Although government schemes have promoted institutional deliveries, many women still incur out-of-pocket expenses for medication, diagnostics, transportation, and other indirect costs. This financial burden discourages women, especially from poor backgrounds, from seeking timely antenatal and delivery care.

4. Reluctance to visit hospitals until full dilation: Many rural women hesitate to visit healthcare facilities during early labour due to the fear of increased C-sections and additional costs. This delay increases the risk of complications such as prolonged labour, fetal distress, and postpartum haemorrhage which require immediate medical intervention.

5. Postpartum haemorrhage and excessive bleeding: One of the leading causes of maternal mortality is excessive bleeding (haemorrhage) during childbirth or the postpartum period. Delayed medical intervention, lack of trained birth attendants, and inadequate blood transfusion services aggravate this risk.

6. Overcrowded secondary healthcare facilities in urban areas: In urban localities, secondary healthcare facilities are overburdened, leading to delays in providing maternal care. In states like Rajasthan, deliveries are not conducted at many PHCs and CHCs which do not operate 24x7, forcing women to rely on congested secondary and tertiary hospitals.

7. Non-adherence to standard operating procedures (SOPs): While many healthcare facilities have shown enthusiasm for quality assessments, some PHCs and smaller facilities still fail to follow SOPs for deliveries, increasing the risk of infections and complications for both mother and child.

8. Shortage of skilled healthcare professionals: A lack of trained gynaecologists, obstetricians, and midwives in rural and underserved areas contributes to poor maternal health outcomes. Many healthcare facilities face human resource shortages, limiting their ability to manage emergency obstetric cases.

9. Inadequate emergency referral and transport services: Delays in emergency referrals and transport coordination hinder timely access to higher-level healthcare facilities. Weak communication between PHCs and secondary hospitals often results in maternal deaths that could have been prevented with quicker medical intervention.

10. Underlying malnutrition and poor pre-pregnancy health: Many women enter pregnancy with pre-existing malnutrition, anemia, or chronic illnesses, which increases their risk of developing complications. Poor nutritional status impacts fetal growth and increases the likelihood of maternal and neonatal deaths.

11. Delayed postnatal care and follow-up: Many maternal deaths occur in the postpartum period due to a lack of adequate postnatal monitoring. Women, especially in rural areas, may not return for follow-up visits, leading to undiagnosed infections, postpartum haemorrhage, or other complications that go untreated.

Even considering the existing challenges, continuity in the present initiatives with greater intent can take all Indian states to the target MMR by or before 2030.

(The writer is a professor and head, Population Research Centre, Institute for Social and Economic Change)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.