Trends in maternal mortality in India over two decades in nationally representative surveys

Abstract

Objective: To assess national and regional trends and causes-specific distribution of maternal mortality in India.

Design: Nationally representative cross-sectional surveys.

Setting: All of India from 1997 to 2020.

Sample: About 10 000 maternal deaths among 4.3 million live births over two decades.

Methods: We analysed trends in the maternal mortality ratio (MMR) from 1997 through 2020, estimated absolute maternal deaths and examined the causes of maternal death using nationally representative data sources. We partitioned female deaths (aged 15-49 years) and live birth totals, based on the 2001-2014 Million Death Study to United Nations (UN) demographic totals for the country.

Main outcome measures: Maternal mortality burden and distribution of causes.

Results: The MMR declined in India by about 70% from 398/100 000 live births (95% CI 378-417) in 1997-98 to 99/100 000 (90-108) in 2020. About 1.30 million (95% CI 1.26-1.35 million) maternal deaths occurred between 1997 and 2020, with about 23 800 (95% CI 21 700-26 000) in 2020, with most occurring in poorer states (63%) and among women aged 20-29 years (58%). The MMRs for Assam (215), Uttar Pradesh/Uttarakhand (192) and Madhya Pradesh/Chhattisgarh (170) were highest, surpassing India's 2016-2018 estimate of 113 (95% CI 103-123). After adjustment for education and other variables, the risks of maternal death were highest in rural and tribal areas of north-eastern and northern states. The leading causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%).

Conclusions: India could achieve the UN 2030 MMR goals if the average rate of reduction is maintained. However, without further intervention, the poorer states will not.

Tweetable abstract: We estimated that 1.3 million Indian women died from maternal causes over the last two decades. Although maternal mortality rates have fallen by 70% overall, the poorer states lag behind.

Keywords: Causes of maternal death; India; UN goals; maternal mortality; trends in maternal mortality.

Figure 1

Trends in maternal mortality ratio (MMR) from 1998 to 2018 and projection for 2020 for India. Each year on the horizontal axis represents the last of each three‐year group for each MMR, except for 1998, which represents the second of two years. The pink bands represent the United Nations (UN)/World Health Organization (WHO) estimates. NFHS‐2 is the National Family Health Survey, 2nd round, and IIHFW is the Indian Institute of Health and Family Welfare survey. Absolute maternal deaths are scaled to the UN demographic totals for females at 15–49 years of age.

Figure 2

Trends in maternal mortality ratio from 1998 to 2018 and projection for 2020 for subnational regions of India. Each year on the horizontal axis represents the last of each three‐year group, except for 1998, which represents the last of two years. EAGA is the Empowered Action Group states plus Assam. Estimates for EAGA from the Annual Health Survey (AHS) data are for two‐year groups. Absolute maternal deaths are scaled to the United Nations demographic totals for females aged 15–49 years.

Figure 3

Spatial distribution of risk‐adjusted maternal mortality ratios (MMRs) in rural areas of India in 2008–2011. The risk of maternal death is adjusted for female literacy, rural/urban status, smoking prevalence, language and spatial clustering effects. States/union territories in India: AP, Andhra Pradesh; AR, Arunachal Pradesh; AS, Assam; BR, Bihar; CH, Chandigarh; CT, Chhattisgarh; DL, Delhi; GA, Goa; GJ, Gujarat; HR, Haryana; HP, Himachal Pradesh; JH, Jharkhand; JK, Jammu and Kashmir; KA, Karnataka; KL, Kerala; MP, Madhya Pradesh; MH, Maharashtra; MN, Manipur; ML, Meghalaya; MZ, Mizoram; NL, Nagaland; OR, Orissa; PB, Punjab; RJ, Rajasthan; SK, Sikkim; TN, Tamil Nadu; TR, Tripura; UL, Uttarakhand; UP, Uttar Pradesh; WB, West Bengal.

Figure 4

Trends in maternal mortality ratio (MMR) in major states (1998–2018) and estimated maternal deaths (2020). Each line starts in 1998 and ends in 2018. *National MMR. The number of years lagging behind the 2018 national MMR is derived from the trends in Figure 1. See Figure 3 for state abbreviations. The blue MMR trend lines represent trends in poorer states (the EAGA states).

Figure 5

Causes of maternal death in India and in selected states, 2007–2014: sepsis (pregnancy‐related infections); others (other obstetric complications); HDP (hypertensive disorders of pregnancy).