A groundbreaking study published in The Lancet Obstetrics, Gynaecology, and Women’s Health has cast a spotlight on India's ongoing challenge with maternal mortality. According to the Global Burden of Disease (GBD) 2023 analysis, India recorded 24,700 maternal deaths in 2023, accounting for roughly one in ten of the world's total 240,000 such deaths. This figure underscores both remarkable progress and persistent hurdles in a nation where pregnancy and childbirth remain risky for many women, particularly in underserved regions.

The maternal mortality ratio (MMR)—defined as the number of maternal deaths per 100,000 live births—stood at 116 (95% uncertainty interval 93.4–138) for India in 2023, down dramatically from 508 (408–618) in 1990. This represents a nearly 80% reduction over three decades, driven by expanded access to healthcare, institutional deliveries, and targeted government programs. Yet, with the United Nations Sustainable Development Goal (SDG) 3.1 aiming for an MMR below 70 by 2030, India still trails the target, highlighting the need for accelerated action.

Global Context: Slowing Progress Amid High Burdens

Worldwide, maternal deaths fell from 423,000 in 1990 to 240,000 in 2023, with the global MMR dropping from 321 to 190.5 per 100,000 live births. However, the pace of decline has slowed since 2015—from an annualised rate of -2.9% (2000–2015) to just -0.5% (2015–2023)—leaving over 100 countries off-track for SDG targets. High-burden nations like Nigeria, the Democratic Republic of the Congo, Ethiopia, Pakistan, and India dominate absolute numbers, primarily in sub-Saharan Africa and South Asia.

Maternal haemorrhage (21.7%) and hypertensive disorders (20.1%) account for over 40% of global deaths, causes that are largely preventable with timely interventions like blood transfusions, antihypertensive drugs, and skilled birth attendants. The COVID-19 pandemic temporarily reversed gains in some regions, but India's trajectory showed resilience post-2022.

India's Impressive Yet Uneven Decline

India's maternal deaths plummeted from 119,000 in 1990 to 36,900 in 2015 and 24,700 in 2023, with MMR trends reflecting annualised changes of -2.0% (1990–2000), -6.7% (2000–2015), and -3.4% (2015–2023). Factors include a surge in institutional deliveries—from under 40% in 2005–06 to over 90% today—and programs like Janani Surakshit Yojana (JSY), which incentivize hospital births.

However, discrepancies exist between GBD estimates and India's Sample Registration System (SRS). The SRS reports an MMR of 88 for 2021–23 (down from 97 in 2018–20 and 130 in 2014–16), suggesting even stronger national progress. Methodological differences—GBD uses modelling from diverse sources, while SRS relies on direct registration—explain the gap, but both affirm a downward trajectory.

Leading Causes and Preventable Factors

In India, as globally, haemorrhage tops causes at around 47% in poorer states, followed by infections (12%), hypertensive disorders, and sepsis. Indirect causes like anaemia, malnutrition, and pre-existing conditions (e.g., diabetes, heart disease) exacerbate risks, especially postpartum. The 'three delays' model—delay in seeking care, reaching facilities, and receiving treatment—remains relevant, rooted in socio-economic barriers, poor roads, and understaffed rural health centres.

• Haemorrhage: Postpartum bleeding, often due to retained placenta or uterine atony; preventable with oxytocin and manual procedures.
• Hypertensive disorders: Preeclampsia/eclampsia; magnesium sulphate is effective but underused.
• Sepsis: From unsafe abortions or prolonged labour; antibiotics and hygiene key.
• Indirect causes: 20–30% of deaths, linked to obesity, hypertension trends rising in urban India.

Recent studies highlight anaemia affecting 57% of pregnant women (NFHS-5), doubling haemorrhage risks.

Regional Disparities: Empowered vs. Achiever States

India's MMR varies starkly: SRS 2020–22 shows Assam (195), Uttar Pradesh (167), and Madhya Pradesh (133) far above the national 88, while Kerala (19), Tamil Nadu (49), and Maharashtra (50) excel. Empowered Action Group (EAG) states—Bihar, Jharkhand, Rajasthan—bear 60% of deaths due to poverty, low literacy (female 65% vs. 82% national), and weak infrastructure.

Urban-rural gap persists: rural MMR 110 vs. urban 85 (SRS 2020-22). Tribal areas lag further, with adolescent pregnancies (10% under 20) amplifying risks.

Government Initiatives Driving Change

India's National Health Mission (NHM) anchors efforts. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) offers free antenatal check-ups on the 9th of every month by specialists. SUMAN (Surakshit Matritva Aashwasan) ensures assured care at public facilities. LaQshya improves labour room quality, reducing infections.

Janani Shishu Suraksha Karyakram (JSSK) provides free transport, drugs, diagnostics for pregnant women and sick newborns. Over 5.93 crore institutional deliveries occurred 2014–24, up from 1.5 crore pre-2014. Pradhan Mantri Matru Vandana Yojana (PMMVY) gives cash incentives for first child nutrition.

• 99% institutional delivery coverage (NFHS-5).
• Skilled birth attendants rose to 89%.
• Maternal Death Surveillance and Response (MDSR) audits 85% deaths for lessons.

Success Stories: Lessons from Leading States

Tamil Nadu slashed MMR from 380+/100,000 in 1993 to 49 today through mandatory audits, 108 ambulance network, and nurse training. Kerala's community health workers ensure 100% antenatal coverage, with MMR at 19.

Rajasthan's 'Mukhyamantri Chiranjeevi Yojana' vouchers private care for poor women, halving MMR in partnered facilities. Jharkhand strengthened first-referral units, cutting deaths 50% via systems thinking. These cases show audits, referrals, and community engagement work.

Ongoing Challenges and Barriers

Despite gains, rural staffing shortages (1 doctor/10,000 vs. WHO 1/1,000), supply gaps (oxytocin stockouts), and cultural delays hinder progress. Malnutrition (35% low BMI pregnant women), climate impacts on food security, and rising non-communicable diseases add layers. Covid disrupted services, but recovery was swift.

Adolescent motherhood (7.9% births to <18), unsafe abortions (8% deaths), and domestic violence compound risks. Data gaps in private facilities (60% urban deliveries) obscure true burdens.

Expert Perspectives and Stakeholder Views

Dr. Abha Majumdar (Sir Ganga Ram Hospital) notes uneven state progress, urging focus on high-risk cases. WHO emphasizes midwifery strengthening. Academics from IHME stress better data for targeting. NGOs like White Ribbon Alliance advocate community scorecards for accountability.

Multi-perspective: Govt highlights institutional surges; critics point quality gaps; researchers call for nutrition integration.

Photo by Raghavendra V. Konkathi on Unsplash

Path Forward: Actionable Insights and Outlook

To hit SDG, India needs 5–6% annual MMR decline. Recommendations: scale PMSMA nationwide, train 1 lakh midwives, fortify iron-folic acid, integrate family planning (TFR 2.0 goal). Tech like telemedicine bridges rural gaps; AI audits predict risks.

• Enhance MDSR to 100% coverage.
• Universal nutrition screening.
• Public-private partnerships for equity.
• Climate-resilient supply chains.

With 25 million annual births, sustained investment could eliminate preventable deaths by 2030. The Lancet study full text urges renewed global-local focus.

Stakeholders agree: equitable, quality care is key. India's journey offers hope, but urgency defines success.