How Can India Lower Its Maternal Mortality Further

This is also the period over which the infant mortality rate (IMR, or deaths of infants under age one for every 1,000 live births) fell from 39 to 25, as per the SRS data.

About 25.5 million children were born in India in 2023, according to an analysis of the SRS data. This means, India had about 22,463 maternal deaths that year.

MMR and IMR are considered a reflection of the quality of and access to services and of the health systems, said Rakhal Gaitonde, a doctor and expert on public health. “The condition of “mortality” is easy to define, and in the case of infant or maternal mortality, is not considered “natural” because otherwise one would expect to live to the average life expectancy,” he explained, adding that it was the duty of the state to ensure safety and provision of services that could prevent these deaths.

Kerala and Andhra Pradesh have the lowest MMR in the country, with Kerala’s MMR falling to 30 this year, less than a third from 91 in 2014-16. However, this is an increase from the figure last year: Kerala’s MMR was 18 in 2020-22.

Was this a statistical error or did these states reverse years of progress on reducing the MMR rendering ineffective all of its interventions in the sphere in just one year? We look for an explanation to the question: how is the statistic measured and what needs to be done to improve it further.

Low fertility or Covid fatality: What explains Kerala’s increasing MMR

The Kerala government attributed the increase in MMR to the addition of Covid-19 deaths to the bulletin. Doctors with whom IndiaSpend spoke confirmed that it was possible, but the reason was more complicated.

“There was an increase in mortality during the pandemic and especially in pregnant women, but then the issue is why it is not showing in other states,” asked Dileep Malvankar, a doctor and researcher who has worked on improving emergency obstetric care in rural hospitals.

The number of maternal deaths due to Covid-19 is so much smaller than the number of live births in a year that the effects of Covid-19 would not show in the MMR, explained public health expert and doctor Rakhal Gaitonde.

MMR is also tied to the number of children being born in a place, according to Gaitonde. “A higher number will increase the number of births taking place and the number of maternal deaths. So MMR will decrease because live births decrease, but also the risk that a mother is faced with during pregnancy decreases.”

The variation could also stem from the way the data are captured and reported. A statistic is estimated within a confidence interval, a range of values within which the true value of the number actually lies. In the case of Kerala, the 95% CI was 2 and 58, meaning that the MMR could be a number between those numbers, explained Gaitonde. Variations in the MMR of the southern states and Bihar, Jharkhand, Chhattisgarh and Odisha could be similarly explained. However, there is a possibility the health system actually has not functioned well enough, a question which can only be answered by an investigation, he added.

Random error, too, could explain the increase in the estimate of MMR, which is susceptible to variation from many sources, according to Gaitonde. “As numbers become smaller and smaller, the tendency to show purely statistical variation increases, as even a few cases mis-classified can make a big overall difference.”

Kerala is in a situation such that any change in indicators has to be carefully studied to discern whether and to what extent the change could be due to statistical variation, minor variations in definition of the phenomenon, data sources, real health system-level changes and constraints, and due to the shift in other factors not directly under the control of the health system, he added. “Changes in many of these indicators take years to show. Politicising such changes and claiming sole credit or blame is a fraught process.”

Mothers’ health and public health

Maternal mortality is a worldwide problem and is influenced by many factors, including whether a country is affected by war, the state of its economy, its healthcare and travel infrastructure, and female access to education. Most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications are well known.

Mothers’ health and longevity is most important to their children. “The mortality of dead women's babies are quite high because they don't get breastfed. They don't get adequate care, et cetera,” said Malvankar.

Lowering maternal mortality requires different interventions at different levels. When MMR is in the 200s or 300s, then a simple measure like ensuring antenatal care visits will help identify women with twin pregnancies, preeclampsia, anaemia, etc., which will bring the MMR to the 90s, explained Gaitonde. (This is where India is at present.)

“To bring the MMR below this, we need skilled birth attendants, strengthen referral centres and focus on secondary and tertiary care. India has moved to skilled birth attendants, but the health systems’ capacity is constrained [to handle referrals], which is why you see a stagnation.”

The bulletin categorises the states into three groups: the eight economically backward states together called the Empowered Action Group (EAG) and Assam; the South; and other states.

The EAG states and Assam have an average MMR of 118 deaths per 100,000 live births–equivalent to South Africa and Yemen. This is nearly triple the average of the southern states (42), equivalent to the ratio in countries such as Mexico and the Seychelles. Other states bring up the middle with an average of 75 maternal deaths per 100,000 live births.

At 153 (the highest in the country), Odisha’s MMR is comparable to that of neighbouring Pakistan and sub-Saharan Botswana. Kerala and AP, which have the lowest ratios, have ratios comparable to Fiji, a group of islands in the South Pacific Ocean.

Since the states are at different stages of progress in lowering MMR, they will require different interventions. More information on these deaths will help strategise for the states. “Kerala needs to focus on strengthening intensive care to handle complicated cases,” said Gaitonde.

IndiaSpend has written to the ministries of health of Kerala, Bihar, Jharkhand, Chhattisgarh and Odisha to ask about possible reasons for the stagnation or worsening of maternal mortality numbers in these states. We will update this story when we receive a response.

Better data required for more focused interventions

If MMR is a measure of health facilities, the improvements in these facilities are felt differently by different women, explained Chhaya Pachauli, a community health worker with Prayaas, a group that works with rural and tribal women in Rajasthan.

Fewer tribal women receive antenatal care or receive poorer quality care than women from non-tribal areas, as we reported in March 2025. Women in remote areas, such as the snow-clad peaks of Himachal Pradesh, give birth in facilities ill-equipped to handle complications, putting them and their children at risk, as we reported in April 2022.

“Where are these deaths happening? Who are the women facing these challenges? Is there a need to relax these requirements? Or is it a matter of infrastructure?”

Gaitonde recommends analysing data on maternal deaths by caste, tribal status and religion to identify the women most in need of access to healthcare. “We need a look at the social determinants of health,” he explained, referring to the non-medical environmental conditions into which people are born and live.

These determinants dictate the experience of motherhood, as Pachauli observed. “PHCs and subcentres (in remote villages) are not equipped with delivery services, so the women have to travel to district hospitals in the case of complications.”

Union and state governments provide financial support and cooked meals to pregnant women with the intention of supplementing their diet. However, the burden of compliance with paperwork leaves many women out of the net of these benefits, she added Pachauli.

“Access to these benefits and basic services is still a problem in our remote, backward village. Women find it harder to reach hospitals, there are no ambulances, etc. They are not aware of the documents required to avail of these schemes, or they don’t have it. Unless the concern of access is addressed, it doesn’t make sense to have more schemes for women,” she added.

This is where village- and block-level data on the causes of maternal death and the condition of the women, made accessible more frequently, can help. “We know that the health workers gather these data and send them to the district- and state-level, but these workers do not have access to these data. If they did, they could make informed decisions in time.”

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