Context

• Maternal mortality remains a critical public health concern in India, reflecting the broader socio-economic, infrastructural, and systemic challenges facing the country's healthcare system.
• While India’s Maternal Mortality Ratio (MMR) has improved, falling from 103 in 2017–19 to 93 in 2019–21, this still translates to 93 women dying for every 1,00,000 live births.
• Therefore, it is important to analyse the various dimensions contributing to maternal mortality in India, highlighting the disparities among different states and strategic solutions.

The National Picture and Regional Disparities

• Empowered Action Group (EAG) States
  • States including Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand, and Assam, represent the most concerning figures.
  • Madhya Pradesh (175) and Assam (167) have alarmingly high MMRs, highlighting acute systemic gaps.
• Southern States
  • Kerala, Tamil Nadu, Andhra Pradesh, Telangana, and Karnataka perform significantly better.
  • Kerala leads the nation with the lowest MMR of 20, exemplifying what committed governance, effective training, and community health initiatives can achieve.
• Other States
  • This list comprises Maharashtra, Gujarat, Punjab, Haryana, and West Bengal and displays a mixed picture, indicating the need for tailored policy interventions to address state-specific challenges.

The Three Delays Model: Understanding Maternal Deaths

• Delay in Decision-Making to Seek Care
  • Often rooted in poor health literacy, financial insecurity, or gendered social norms, this delay can be fatal.
  • Families underestimate complications, assuming childbirth is a routine process.
  • However, community engagement through ASHA workers, self-help groups, and financial incentives under the National Rural Health Mission have begun to shift attitudes, promoting institutional deliveries.
• Delay in Reaching Healthcare Facilities
  • Geographic isolation, inadequate transportation, and poor road connectivity are barriers in rural and tribal areas.
  • The 108-ambulance service and emergency transport provisions under the National Health Mission have mitigated this to some extent, but challenges persist.
• Delay in Receiving Adequate Care at the Facility
  • This is perhaps the most inexcusable of all delays.
  • Systemic issues like understaffed hospitals, lack of blood banks, absence of skilled obstetricians or anaesthetists, and delayed emergency response contribute significantly to avoidable deaths.
  • A non-functional operation theatre or delayed availability of lab results can mean the difference between life and death.

Medical Causes of Maternal Mortality

• Postpartum Haemorrhage
  • The leading cause, often due to uterine atony, which can lead to massive blood loss.
  • In the absence of timely blood transfusion and uterine contraction management, death occurs swiftly.
• Obstructed Labour
  • Especially prevalent among malnourished, stunted women with narrow pelvic structures.
  • Without timely Caesarean sections, prolonged labour can cause uterine rupture and foetal death.
• Hypertensive Disorders: Conditions like preeclampsia and eclampsia are often undetected and untreated, resulting in seizures, coma, or death.
• Sepsis: Caused by unsafe home deliveries or crude abortion practices, particularly in areas with poor access to contraception and trained medical personnel.
• Coexisting Illnesses: Diseases like tuberculosis, malaria, and urinary tract infections compound maternal risk, especially in underdeveloped states.

Models of Success: Learning from Kerala

• Kerala’s approach stands out as a national and even global benchmark.
• The state’s implementation of the Confidential Review of Maternal Deaths, pioneered by Dr. V.P. Paily, has helped identify and address avoidable causes.
• Strategies such as early use of uterine artery clamps, management of amniotic fluid embolism, and proactive treatment of antenatal depression exemplify a comprehensive model of care.
• This goes beyond the physical to address the psychological and social aspects of maternal health.
• This proactive approach, backed by routine audits, robust training, and community engagement, should serve as a template for other states, particularly in the south and parts of western India.

Recommendations and the Way Forward

• Enhance Antenatal Care: Early registration, regular check-ups, and management of pre-existing conditions must be rigorously implemented.
• Strengthen Institutional Deliveries: Public awareness campaigns and incentives must continue, especially in high-risk zones.
• Upgrade First Referral Units (FRUs): Each district must have fully functional FRUs with emergency obstetric services, a 24x7 blood bank, and trained personnel.
• Expand Human Resources: Training and deploying more obstetricians, anaesthetists, and nurses in rural areas is essential. Task-sharing models and telemedicine can also help bridge gaps.
• Robust Transport Mechanisms: Ambulance systems need to be expanded and better integrated with community health networks.

Conclusion

• Maternal mortality is not merely a health issue; it is a reflection of a society’s commitment to the well-being of its women.
• While India has made commendable progress in reducing MMR, the journey is far from over.
• The existence of high-performing models like Kerala proves that with political will, systemic investment, and community involvement, preventable maternal deaths can be a thing of the past.
• The tragedy of 93 women dying out of every one lakh live births should not be normalised and it is both a challenge and a call to action, for policymakers, healthcare professionals, and society at large.