The Maternal Mortality Ratio (MMR) for India is on the decline, but there are States that need to focus on basic and systemic issues.

Current Status of Maternal Mortality in India

• About Maternal Death: Maternal death is 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.
  • It is defined as the number of maternal deaths per 100,000 live births during a specific time period.
  • The Maternal Mortality Ratio (MMR) for India was 93 maternal deaths per 100,000 live births for the period 2019–21, as reported under the Sample Registration System (SRS). 
• India has seen a decline in MMR from 103 in 2017–19, to 97 in 2018–20, and finally to 93 in 2019–21.

State-wise Classification for Maternal Mortality

States are categorised into three groups to better understand the maternal mortality situation and a differential strategy is vital for each cluster of states to reduce maternal deaths.

• Empowered Action Group (EAG) States: These include Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand, and Assam.
  • Assam exhibits a very high MMR of 167.
  • Jharkhand performs better within this group with an MMR of 51.
  • Bihar, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, and Uttarakhand fall in the 100–151 range.
• Southern States: This group comprises Andhra Pradesh, Telangana, Karnataka, Kerala, and Tamil Nadu.
  • Kerala boasts the lowest MMR in the country at 20.
  • Karnataka has the highest in this group at 63.
• Other States: This category covers the remaining States and Union Territories.
  • Maharashtra has an MMR of 38, and Gujarat is at 53.
    

The “Three Delays” Leading to Maternal Deaths

• First Delay: Delay in Recognising Danger and Deciding to Seek Expert Care
  Causes: Family members often show inertia, believing childbirth is purely a natural process requiring patience. 
  • Financial constraints and a lack of awareness or education within families also hinder timely decision-making to seek hospital care.
    • Initiatives to solve this: Empowered local mothers and women’s self-help groups have significantly changed this scenario, preventing neglect of expectant mothers by family members. 
    • The Accredited Social Health Activists (ASHA), networking with Auxiliary Nurse Midwives (ANM) since the launch of the National Rural Health Mission (NRHM) in 2005, have promoted institutional deliveries over home births. 
    • Financial incentives provided to both mothers and ASHA workers have further encouraged hospital deliveries.
• Second Delay: Delay in Transportation to a Health Facility
  • Many women die en route to health facilities, particularly from remote rural areas, forest settlements, or islands, where reaching a hospital can take many hours or even an overnight journey.
    • Initiatives to solve this: The 108 ambulance system and other emergency transport mechanisms under the National Health Mission have proven vital in making a difference by ensuring timely access to healthcare facilities.
• Third Delay: Delay in Initiating Specialised Care at the Health Facility
  • Delay once a mother reaches a hospital: Excuses for this delay are numerous and often unjustified, including: 
    • Delay in attending to a woman in the emergency room, 
    • Delay in the obstetrician reaching the patient, 
    • Lack of readily available blood donors or laboratory support, 
    • Operation theatres not being ready or anaesthetists being unavailable etc.
  • Infrastructure Deficiencies: The concept of operationalizing a minimum of four First Referral Units (FRUs) per district of two million population is crucial but has not worked as expected since 1992. 
    • There is a severe 66 percent vacancy of specialists in community health centres designated as FRUs. 
    • Furthermore, the lack of adequate blood banks or blood storage units in these FRUs leads to fatalities due to insufficient blood transfusions.

Other Causes of Maternal Deaths

• Bleeding After Delivery (Postpartum Haemorrhage): Profuse bleeding occurs if the uterus does not contract adequately after delivery, especially with larger babies.
  • A significant loss of blood can lead to shock and death. 
  • Pre-existing anaemia further exacerbates this risk. 
  • Immediate blood transfusion and emergency surgical care are critical.
• Obstructed Labour: This occurs when the baby cannot emerge due to a contracted bony pelvis in an underdeveloped or malnourished mother, leading to prolonged labour, foetal distress, and potential uterine rupture. 
  • A Caesarean section is necessary in such cases, demanding a well-equipped operation theatre and readily available surgical specialists.
• Hypertensive Disorders of Pregnancy: If not recognised and treated promptly, these can lead to severe emergencies, including convulsions and coma, with little time to control high blood pressure.
• Infections (Sepsis): Unhygienic home deliveries by untrained attendants can lead to trauma and puerperal infection, causing sepsis and death. 
• • Late hospital admissions further complicate these cases. 
  • Unwanted pregnancies leading to crude abortion techniques by quacks also result in sepsis and death.
• Associated Illnesses: In EAG states, co-existing conditions like malaria, chronic urinary tract infections, and tuberculosis significantly increase the risk during pregnancy and childbirth.
  

Way Forward

• Comprehensive Care: There is a need to ensure comprehensive maternal care through early pregnancy registration, routine antenatal check-ups, institutional deliveries, and sustained postnatal care for at least 42 days.
• Systemic Strengthening:
  • Mandatory reporting and auditing of all maternal deaths under the National Health Mission (NHM) are essential to identify systemic deficiencies and improve quality of care
  • EAG States must focus on implementing basic tasks and strengthening fundamental infrastructure
  • Southern states, along with Jharkhand, Maharashtra, and Gujarat, need to refine the quality of their emergency and basic obstetric care
  • Learning from the Kerala model of Confidential Review of Maternal Deaths, which provides analytical insights, can help other states further reduce their MMR
• Addressing Specific Challenges:
  • Ensuring the availability of specialists such as obstetricians, anaesthetists, and paediatricians at FRUs
  • Guaranteeing blood banks and operational theatres are readily available and fully functional
  • Implementing advanced medical methods for managing complications like postpartum bleeding and other critical conditions, although some of these are still not routinely practised even in developed countries
  • Addressing antenatal depression and postpartum psychosis, as psychological stress can also contribute to adverse outcomes

Conclusion

Ultimately, the commitment to stop maternal deaths requires a collective effort: proactive intervention, widespread awareness, and decisive action from both families and the healthcare institutions.

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