Maternal mortality: India’s trajectory to sustainable development goal 2030

Pregnancy-related mortality and morbidity have a significant impact on the lives of both women and neonates. Globally, approximately 287,000 women died from pregnancy complications in 2020, which corresponds to approximately 800 women dying every day or one woman every 2 min.[1] Maternal mortality remains a significant public health issue in India, with substantial inter-and intra-state differences in health service utilisation and maternal deaths. The United Nations (UN) has set a Sustainable Development Goals (SDGs) target to reduce the Maternal mortality ratio (MMR)to <70 by 2030. Although a significant reduction has been achieved, there still is a long way to go. DEFINITIONS The ICD 11 classification, implemented from 1 January 2022, has the following definitions:[1] A maternal death: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy but not from accidental or incidental causes, and including Direct deaths Indirect deaths HIV-related indirect deaths. A late maternal death is “the death of a woman from direct or indirect obstetric causes, more than 42 days but <1 year after the termination of pregnancy.” The MMR calculation does not include late maternal deaths because of international comparability Comprehensive maternal deaths: Combining maternal and late maternal deaths Pregnancy-related deaths: The death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the cause of death. This definition allows measurement in settings where accurate information about the causes of death is unavailable but is not strictly considered ‘maternal death’. Maternal mortality ratio (MMR)[1] MMR: Number of maternal deaths per 100,000 live births during the same period Maternal mortality rate (MMRate): The number of maternal deaths divided by person-years lived by women of reproductive age (ages 15–49 years) in a population during the same period Lifetime risk of maternal death: The probability that a 15-year-old girl will die from a maternal cause Proportion maternal (PM): The number of maternal deaths divided by the total deaths among women aged 15–49 years. MATERNAL MORTALITY DATA SOURCES Reliable reporting, quantification and understanding of the major causes of maternal deaths are critical for effective action and require continuous improvement. Two types of errors commonly affecting the accuracy of data[1] are incomplete (common in rural and remote areas of India where maternal deaths are most concentrated) and misclassification (when the cause of death is not recorded accurately as per ICD classification). Data Sources: In India, the Sample Registration System (SRS) is a demographic survey conducted by the Registrar General of India (RGI), which provides birth and death data for the country. Other sources of information include the National Family Health Survey, the Indian Institute of Health and Family Welfare and the Annual Health Survey for nine poorer states. The UN Maternal Mortality Estimation Inter-Agency Group (MMEIG), along with external technical experts, has produced robust estimates of maternal mortality for the period 2000–2020. CURRENT TRENDS As per the MMEIG 2020 report,[1] the decline in the MMR in India was from 384 in 2000 to 103 in 2020, whereas it was from 339 in 2000 to 223 in 2020 globally. The average annual reduction rate (ARR) in the MMR of 6.36% in India was significantly higher than the global decline of 2.07% during the 2000–2020 period. In India, maternal mortality varies significantly across regions, owing to variations in health infrastructure, service delivery, social determinants and other factors. The RGI categorised Indian states[2] into poorer Empowered Action Group states plus Assam (EAGA) and wealthier states, including the rest. EAGA, which has a high MMRate, is a primary focus of the National Health Mission. Table 1 shows the measures of maternal mortality for the period 2018–2020.[2] All states were further divided into rural and urban areas. In poorer states, rural areas have less access to skilled birth attendants and emergency obstetric services than metropolitan areas. In contrast, in wealthier states, there are no rural–urban differences.[3]Table 1: Measures of maternal mortality for the period 2018–2022[ 2 ]As per SRS Bulletin[2] in 2022, India’s MMR has improved to 103 for the years 2017–2019, marking an 8.8% decline [Figure 1]. Some states still have high MMRate despite improvements in the national average.Figure 1: Trends in maternal mortality ratio in India.[ 2 ] MMR: Maternal mortality ratioThe proportion of maternal deaths (PM) decreased from 12% to 4% between 1997 and 2020.[4] The MMR decline was correlated with increasing institutional births (P < 0.0001). The MMR in the EAGA states was twice as high as that of the other states, although the percentage declines were similar (5.9% in EAGA and 6.3% in the other states). India accounted for 12% of global maternal deaths in 2017 (MMR of 145), as per UN estimates. According to the WHO, about 40% of the substantial global decline in MMR from 342 to 211 between 2000 and 2017 was attributed to fewer maternal deaths in India.[4] DISTRIBUTION OF CAUSES OF MATERNAL DEATH IN INDIA The distribution of causes of maternal mortality changes with MMR levels, as increasing healthcare utilisation leads to a reduction in preventable maternal deaths. The leading cause of maternal death[4] in India was haemorrhage (47%; more in poorer states), followed by infection (12%) and hypertensive disorders of pregnancy (7%). The distribution of causes was the same in poor and prosperous states, suggesting a limited contribution of one or more specific causes to death. Montgomery et al.[3] also reported a similar distribution of causes in poor and rich states or rural and urban areas. Direct causes (81.8%) contributed to most maternal deaths, with 25% being obstetric haemorrhage and indirect causes of 15% of deaths. In Delhi, a tertiary care referral hospital, GTBH and UCMS, reported 146 maternal deaths and 18,000 live births in 2023 (unpublished data). Direct causes contributed to approximately 74% (sepsis, 33%; haemorrhage, 23%; HT, 13%; others, 5%) while indirect causes accounted for 26%. PROGRESS AND TRAJECTORY TOWARDS ACHIEVING SUSTAINABLE DEVELOPMENT GOAL TARGET 3.1 With a global MMR of 223 in 2020, bringing it below 70 by 2030 will require an average ARR of 11.6% for the remaining 10 years.[1] As per the SRS report,[2] India is on the path to achieving an SDG target of MMR of 70. Seven states achieved the target, and nine achieved the National Health Policy MMR target of 100. Projections by Meh et al.[4] suggest that by 2030, India will exceed the UN SDG target, reaching an MMR of 52, as will the other states that will reach an MMR of 35, whereas the EAGA states are unlikely to meet the target, with a projected MMR of 78.[4] The WHO has emphasised ending preventable maternal mortality (EPMM) to achieve the SDG goal.[1] Most of this is preventable with the available clinical expertise and technology, but it is underutilised. In India, the quality of emergency obstetric care is a major determinant of maternal mortality. Planned institutional births sometimes result in deaths occurring at home or en route. In health institutions, a high proportion of deaths occur due to unanticipated obstetric emergencies, such as haemorrhage.[5] In India, the following measures may help in EPMM. Policies to identify, address and monitor disparities in EAGA states and rural and tribal areas through infrastructure, staffing and training investments Women’s health education regarding antenatal care and institutional delivery Capacity-building of skilled healthcare providers Reliable estimation of maternal deaths, surveillance and timely responses. GOVERNMENT OF INDIA INITIATIVES TO REDUCE MATERNAL MORTALITY RATIO Multisectoral interventions are required to reduce maternal mortality. Some of these actions range from improvements in health service delivery to measures that address social and structural barriers.[5] The reductions in MMR result from successful initiatives by the Government of India (GOI), stakeholders, national policies and the National Health Mission. Many schemes such as ‘Pradhan Mantri Surakshit Matritva Abhiyan’, Janani Suraksha Yojana, LaQshya (Quality Improvement Initiatives), Monthly Village Health, Sanitation and Nutrition Day are implemented across the country to improve maternal health. MATERNAL DEATH SURVEILLANCE AND RESPONSE The GOI introduced the maternal death surveillance and response (MDSR) system in 2017, replacing the Maternal Death Review process initiated in 2010. It is a continuous cycle of identifying, notifying and reviewing maternal deaths along with Confidential Review, in which an anonymous investigation is conducted on all or a sample of maternal deaths by multidisciplinary teams. All maternal deaths are to be reported and investigated irrespective of the place of death at both the community (verbal autopsy format) and facility levels. The guidelines reiterate the non-punitive nature of MDSR and state that the purpose is to identify gaps, take appropriate corrective measures for quality improvement, reduce future deaths and sensitise service providers to enhance accountability. In conclusion, India’s monumental efforts to reduce the MMR by 70% between 2000 and 2020 have positioned the country to achieve the SDG 2030 target of an MMR below 70, albeit with some interstate inequities. To achieve and sustain uniform results, all private and public partners require multisectoral commitment and efforts to reduce preventable maternal mortality and ensure women’s health.