08 Jul 2025 : Fostering a commitment to stop maternal deaths

 Editorial 1: Fostering a commitment to stop maternal deaths

Context

The number of mothers dying during childbirth is going down in India, but some states still need to work on fixing basic and deep-rooted problems in healthcare.

Introduction

Why should 93 women die during childbirth in India when one lakh women have a safe delivery? Between 2019–21, India’s Maternal Mortality Ratio (MMR) was 93, meaning 93 women died for every 1,00,000 live births, according to the Sample Registration System (SRS). Maternal death means the death of a woman during pregnancy or within 42 days after its end, due to causes linked to the pregnancy or its treatment, not due to accidents or unrelated reasons. However, India's MMR has been falling over the years — it was 103 in 2017–19, then 97 in 2018–20, and now 93 in 2019–21.

Categorisation of States Based on Maternal Mortality Ratio (MMR)

Key Insight

• Kerala has the lowest MMR among all states (20).
• Madhya Pradesh and Assam have the highest MMRs in the country (175 and 167 respectively).
• This shows the need for a differentiated strategy based on each state's specific needs and health infrastructure.

Three Major Delays in Preventing Maternal Deaths

Key factors that endanger a life

First Delay – Delay in Recognising Danger and Deciding to Seek Care

• The first delay is in recognising danger and deciding to seek expert care.
• Husbands and family members often show inertia, assuming childbirth is natural and the mother can wait.
• Families may not go to the hospital due to:
  • Lack of money
  • Family-level issues
• If the education and financial condition of the family is weak, decision-making is delayed and harmful.
• Empowered neighbourhood mothers and women’s self-help groups (SHGs) have brought remarkable change.
• The mother-to-be is no longer neglected by lethargic family members.
• Since 2005, ASHA workers have been networking with ANMs under the National Rural Health Mission (NRHM).
• Institutional deliveries have become more common than home deliveries.
• Financial incentives for both mothers and ASHA workers were the turning point.

Second Delay – Delay in Reaching Health Facility

• The 108 ambulance system and emergency transport services under the National Health Mission (NHM) have made a difference.

Third Delay – Delay in Providing Specialised Care at the Health Facility

• The third delay, often unpardonable, happens at the hospital itself.
• Common excuses and delays include:
  • Delay in attending the woman in the emergency room
  • Delay in reaching the obstetrician
  • Delay in arranging a blood donor
  • Delay in lab tests, operation theatre, or anaesthetist

Importance of First Referral Units (FRUs)

• Introduced in 1992, but has not worked as expected.
• Key issues:
  • 66% vacancy of specialists in 5,491 CHCs (out of which 2,856 are FRUs).
  • Lack of blood banks or storage units delays urgent transfusion.
  • Fatalities occur if blood is not given within 2 hours of heavy bleeding.

Medical Causes of Maternal Deaths

What’s Needed

• Immediate blood transfusion
• Well-equipped OT, with obstetrician, surgeon, and anaesthetist on call
• Timely recognition and treatment of high blood pressure
• Safe delivery practices
• Access to antibiotics, and prevention of unsafe abortions
• Address underlying diseases like malaria and TB, especially in EAG States

Prescription for Preventing Maternal Deaths

• Early registration of pregnancy is essential to track and monitor maternal health.
• Regular antenatal check-ups help identify risks during pregnancy.
• Promoting institutional delivery ensures access to skilled medical care.
• These steps help in early detection of complications before they turn serious.
• Under the National Health Mission (NHM), mandatory reporting and audit of all maternal deaths is carried out.
  • The purpose is to highlight systemic deficiencies in maternal care services.
• State-specific priorities must guide interventions:
  • EAG States need to focus on basic implementation tasks.
  • Southern States, Jharkhand, Maharashtra, and Gujarat must improve the quality of basic and emergency obstetric care.
• The Kerala model, known as the Confidential Review of Maternal Deaths, was initiated by Dr. V.P. Paily.
  • Kerala’s MMR is 20, among the lowest in India.
  • The model offers insights that other southern States can adopt.
  • Focus is on refining clinical practices and response systems.
• Advanced strategies followed in Kerala include:
  • Use of uterine artery clamps on the lower uterine segment.
  • Suction canula application to address uterine atonicity.
  • Active monitoring for:
    • Amniotic fluid embolism
    • Disseminated intravascular coagulation (DIC)
    • Hepatic failure from fatty liver cirrhosis
• Kerala also addresses mental health conditions like:
  • Antenatal depression
  • Post-partum psychosis
  • Reported cases of maternal suicide are taken seriously and managed accordingly.

Conclusion

Reducing maternal deaths requires timely care, institutional deliveries, and strong healthcare systems. While India’s MMR is improving, deep gaps remain across states. A focused, state-wise approach, backed by trained personnel, emergency support, and models like Kerala’s, is essential. With commitment and accountability, no woman should lose her life giving birth — a basic right, not a privilege.