1. OVERVIEW OF MATERNAL HEALTH GLOBALLY AND IN INDIA

This section provides a brief history of global maternal health, while mapping the landscape, key initiatives, and current challenges within the Indian context.

1a. Introduction to Global Maternal Health Maternal health refers to the health of women during pregnancy, childbirth, and the postnatal period. Women contribute to society by bearing children, and it is society’s responsibility to ensure their health and safety. Unfortunately, around 700 women still die each day globally from complications in pregnancy and childbirth [1].

Reducing maternal and infant morbidity and mortality is a key goal of public health and development efforts. Most maternal deaths can be prevented with timely intervention and management by skilled health personnel – doctors, nurses, or midwives – who have the proper equipment and supplies. Under the Sustainable Development Goals (SDGs), there is a global target to reduce the maternal mortality ratio (MMR) i.e., the number of maternal deaths per 100,000 live births, to less than 70 by 2030.

There has been a remarkable improvement in maternal health in recent decades - the number of women who died annually worldwide, from complications of pregnancy and childbirth, declined from 451,000 in 2000 to 295,000 in 2017 [2]. However, achieving the SDG target requires continued investment in maternal health research, programmes, and policies.

1b. Introduction to Maternal Health and Key Initiatives in India India has made steady progress towards improving maternal and newborn health through a range of programs and initiatives. As per the National Sample Registration System (SRS), the maternal mortality ratio (MMR) has improved to 103 in 2017-2019, as compared to earlier numbers of 113 in 2016-2018, 122 in 2015-2017, and 130 in 2014-2016 [3].

In the early part of this century, programmes focused on ensuring pregnant women in India had access to healthcare and gave birth in healthcare facilities. Programs to strongly encourage and incentivize institutional delivery such as the Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) were launched under the 2005 National Rural Health Mission, along with schemes such as the 2016 Pradhan Mantri Surakshit Matritva Abhiyan to provide antenatal care.

Institutional births have increased significantly from 79% (2015-16) to 89% (2019-21) at the national level. Despite increased access to modern healthcare facilities, data showed that about 46% of maternal deaths, more than 40% of stillbirths, and 25% of under-5 deaths were still on the day of birth [5]. Attention thus shifted to improving the quality of care provided during institutional deliveries, through programs such as the LaQshya quality improvement initiative in 2017 and Surakshit Matritva Aashwasan (SUMAN) in 2019.

1c. Maternal Health Challenges in India Although India is on track to meet the SDG targets for Maternal Mortality Ratio (MMR), there remains significant room for improvement. A more inclusive and resilient healthcare system is essential to enhance quality of care, and address issues stemming from an under skilled and inadequate healthcare workforce, and widespread disrespect and abuse across the country.

1ci. Poor Quality of Care in Institutions – Too Little, Too Late, and Too Much, Too Soon Poor quality of care in India is expressed as both inadequate care and as excessive intervention. This dual challenge is known as ‘Too Little, Too Late’ (TLTL) or ‘Too Much, Too Soon’ (TMTS). TLTS refers to maternal care with inadequate resources, care that is below standards, or care withheld or unavailable until it is too late to help. Inadequate staffing levels, poor availability of physical infrastructure, a weak referral system, and an inadequately skilled workforce all contribute to TLTL.

On the other hand, ‘Too Much, Too Soon’ is rapidly growing. TMTS is the routine over-medicalization of normal pregnancy and birth by the unnecessary use of non-evidence-based interventions or the use of interventions that can be life-saving when used appropriately but harmful when applied routinely or overused. Rates of c-sections, inductions, augmentations, and episiotomies in India are much higher than recommended by clinical guidelines and protocols, resulting in unnecessary morbidity and harm for mothers and babies, and increased costs to the healthcare system. Overuse of Caesarean surgeries is particularly acute in private hospitals. State-level c-section rates in the private sector are now more than 80% in Jammu & Kashmir, Telangana, and West Bengal [6].

The TLTS or TMTS dual challenge is in large part due to the inadequate healthcare workforce. The number of doctors and nurse-midwives in India is well below the WHO recommended levels, and research shows that not only are a large number not adequately qualified, there is a highly skewed distribution of healthcare workers across states, rural–urban and public–private sectors. [7]

1cii. Widely Prevalent Disrespect and Abuse Disrespect and abuse (D&A) is widely prevalent both globally and in India and cuts across all socio-economic segments of society. It includes physical harm, discrimination and coercion based on one’s socio-economic status, non-consented care, lack of privacy and confidentiality, and more [8]. Women face disrespect and abuse whether in the over-stretched public healthcare system, where it may take forms such as lack of privacy and verbal abuse, or the hospital-centric private healthcare system, where lack of informed consent and lack of autonomy are more common.

Disrespect and abuse is an inherent violation of human rights and also contributes to maternal mortality and morbidity by affecting whether women seek medical help. It is striking that in a worldwide campaign run by the White Ribbon Alliance (WRA) called ‘What Women Want!’, the top demand from more than 1 million women from 114 countries was respectful and dignified healthcare [9].

References

[1] WHO, World Health Organization. 2019. “Maternal Mortality.” World Health Organization. Accessed July 24, 2025. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

[2] UNICEF, United Nations Children's Fund. “Maternal Health.” UNICEF India. Accessed July 24, 2025. https://www.unicef.org/india/what-we-do/maternal-health.

[3] MoHFW, Ministry of Health and Family Welfare. 2022. “India on verge of achieving SDG target of Maternal Mortality Ratio (MMR) of 70/ lakh live births by 2030.” Press Information Bureau Delhi. Accessed July 24, 2025. https://pib.gov.in/PressReleasePage.aspx?PRID=1805731​

[4] MoHFW, Ministry of Health and Family Welfare. 2025. “Saving Mothers, Strengthening Futures India’s Success in Reducing Maternal Mortality.” Press Information Bureau Delhi. Accessed July 24, 2025. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2113800

[5] MoHFW, Ministry of Health & Family Welfare. “Labour Room & Quality Improvement Initiative.” National Health Mission. Accessed July 24, 2025. https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1307&lid=690​

[6] MoHFW, Ministry of Health and Family Welfare. International Institute for Population Sciences (IIPS) and ICF. 2021. National Family Health Survey (NFHS-5), 2019-21: India: Volume II. Mumbai: IIPS. https://dhsprogram.com/pubs/pdf/FR375/FR375.pdf

[7] Karan, A., Negandhi, H., Hussain, S. et al. Size, composition and distribution of health workforce in India: why, and where to invest?. Hum Resour Health 19, 39 (2021). https://doi.org/10.1186/s12960-021-00575-2

[8] White Ribbon Alliance for Safe Motherhood. 2020. “Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns.” The White Ribbon Alliance for Safe Motherhood. https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf

[9] WRA, The White Ribbon Alliance. 2019. “What Women Want!”. https://whiteribbonalliance.org/wp-content/uploads/2022/05/What-Women-Want_Global-Results.pdf

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