Maternal health

1. Scope, indicators and rights-based foundations

Maternal health extends beyond surviving childbirth. It includes preconception nutrition, safe pregnancy, respectful delivery care, postpartum recovery, mental health and access to contraception. Maternal morbidity includes haemorrhage, hypertensive disorders, infection, obstetric fistula and other conditions that may cause prolonged disability. A maternal near miss occurs when a woman nearly dies but survives a complication during pregnancy, childbirth or within 42 days of pregnancy termination. Studying near misses reveals system failures that mortality statistics alone cannot capture.

MMR measures obstetric risk relative to live births. The maternal mortality rate instead relates maternal deaths to the population of women of reproductive age. Monitoring should also cover antenatal contacts, anaemia, skilled birth attendance, emergency obstetric care, postnatal follow-up and financial protection. Institutional delivery is an important intermediate indicator, but a birth inside a facility does not automatically mean that timely, competent and dignified care was provided.

The constitutional framework includes Article 21’s protection of life and dignity, Article 42’s directive concerning maternity relief, and Article 47’s emphasis on nutrition and public health. Public health and hospitals are primarily State List subjects, while the Union supports standards, financing and programmes. The National Health Mission therefore depends on effective Centre–State coordination. A rights-based approach treats women as decision-makers entitled to informed consent, confidentiality and non-discriminatory care, rather than merely as beneficiaries.

• Maternal health is closely linked to SDG 2 on nutrition, SDG 3 on health, SDG 5 on gender equality and SDG 6 on water and sanitation.
• Preconception and inter-pregnancy services are essential: pregnancy care alone cannot reverse lifelong nutritional and social deprivation.

2. Causes of mortality and unequal access

Major direct causes of maternal death include obstetric haemorrhage, hypertensive disorders such as pre-eclampsia and eclampsia, sepsis, complications of delivery and unsafe abortion. Indirect causes include conditions such as anaemia and heart disease that pregnancy may aggravate. Severe anaemia reduces a woman’s ability to withstand blood loss. Prevention therefore requires nutrition and primary care alongside round-the-clock emergency treatment, blood availability and effective referral systems.

The three-delays model explains how social disadvantage becomes a clinical emergency. The first delay concerns deciding to seek care, influenced by awareness, household authority, cost and previous mistreatment. The second concerns reaching an appropriate facility, especially in remote, tribal, flood-prone or hilly areas. The third occurs after arrival because of delayed triage, unavailable specialists, blood shortages or repeated referrals. An ambulance cannot solve a referral problem if the receiving hospital lacks capacity.

Adolescent pregnancy, closely spaced births, poverty, unpaid care burdens and limited reproductive autonomy increase vulnerability. Migrant women may lose continuity of records and benefits, while women with disabilities may face inaccessible facilities. NFHS-5 reported that only 58.1% of mothers had at least four antenatal visits, illustrating the gap between widespread institutional delivery and sustained pregnancy care. State averages must therefore be supplemented by district-level and socially disaggregated monitoring.

• Analyse maternal health through both clinical causes and structural determinants: education, food security, transport, sanitation and gender relations.
• Avoid interpreting every maternal death as an individual failure to seek care; health-system readiness and responsiveness are equally important.

3. India’s policy and programme architecture

The National Health Mission supports a continuum of reproductive, maternal, newborn, child and adolescent health services. Accredited Social Health Activists mobilise women, facilitate antenatal registration and institutional delivery, and connect households with services. Auxiliary Nurse Midwives, staff nurses, community health officers and medical officers provide primary-level care and identify risks. Referral facilities must complement this outreach with skilled delivery services, surgical capability, anaesthesia and blood transfusion where required.

Janani Suraksha Yojana, launched in 2005, uses conditional cash assistance to promote institutional delivery, with eligibility and benefits varying by state category and beneficiary group. Janani Shishu Suraksha Karyakram, launched in 2011, provides entitlements in public facilities including free delivery and caesarean section, drugs, diagnostics, diet, blood and transport. The distinction is important: JSY primarily encourages service use, whereas JSSK seeks to remove expenditure barriers associated with accessing care.

Pradhan Mantri Surakshit Matritva Abhiyan provides assured antenatal services on the ninth of each month, particularly during the second and third trimesters, and helps identify high-risk pregnancies. LaQshya focuses on quality improvement in labour rooms and maternity operation theatres. SUMAN, launched in 2019, seeks assured, dignified and respectful care without cost and with zero tolerance for denial of services. These initiatives address different weaknesses and should operate as an integrated pathway rather than isolated campaigns.

Pradhan Mantri Matru Vandana Yojana provides maternity benefits to eligible women. Under PMMVY 2.0, assistance is ₹5,000 for the first child and ₹6,000 for the second child when the second child is a girl, subject to scheme conditions. Anaemia Mukt Bharat and POSHAN interventions address nutritional risks. The Maternity Benefit Act, as amended in 2017, provides up to 26 weeks of maternity leave for eligible women with fewer than two surviving children in covered establishments, but comprehensive income protection remains difficult for many informal workers.

4. Quality, reproductive autonomy and accountability

The central policy challenge is shifting from counting contacts and deliveries to assuring effective coverage. A complete antenatal assessment should detect hypertension, anaemia and other risks, support birth preparedness and establish a referral plan. However, complications can arise even in pregnancies classified as low risk. Universal readiness for emergencies is therefore as important as tracking high-risk women. Postnatal care must also address bleeding, infection, breastfeeding difficulties, contraception and maternal mental health.

Respectful maternity care requires privacy, consent, clear communication, freedom from abuse and appropriate birth companionship. Unnecessary procedures and denial of necessary interventions are both failures of quality. NFHS-5 found that caesarean sections accounted for 47.4% of births in private facilities, compared with 14.3% in public facilities. These figures warrant examination of clinical need, referral case mix and incentives; they do not establish that every private-sector caesarean is unnecessary.

Access to lawful, safe abortion is an integral component of maternal health. The Medical Termination of Pregnancy Act, 1971, amended in 2021, permits termination subject to specified conditions and medical opinions. For prescribed categories, termination between 20 and 24 weeks requires the opinions of two registered medical practitioners. The Act protects confidentiality. Legal permission must be accompanied by trained providers, accessible facilities and accurate information; otherwise unsafe practices may persist.

• Maternal Death Surveillance and Response should identify avoidable factors and ensure corrective action rather than become a blame-oriented exercise.
• Near-miss reviews, confidential feedback and grievance redressal can reveal deficiencies that routine reporting misses.

5. Priorities for equitable maternal health

India needs stronger public financing for functional services, not merely additional buildings. Priority investments include competent midwifery and nursing teams, reliable medicines, emergency obstetric services, blood access and referral coordination. District planning should map travel times and facility capabilities, with appropriate arrangements for remote populations. Competency-based training and supportive supervision are more useful than one-time training certificates.

Financial protection must cover direct expenditure and indirect costs such as travel, food, lost wages and accompanying caregivers. Nutrition, schooling, prevention of child marriage and voluntary family planning should converge with health services. Digital pregnancy tracking can improve continuity, but registration problems, authentication failures or lack of a phone must not become grounds for denying care. Personal health information also requires safeguards.

A balanced accountability framework should assess deaths, near misses, respectful care, out-of-pocket expenditure and timely treatment. Local health institutions and community organisations can help identify barriers, while states adapt national schemes to regional needs. The overarching objective is not simply more institutional births, but safe, wanted pregnancies and dignified care throughout the reproductive life course.

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