Introduction
Maternal mortality deals with death of women from complications of pregnancy or childbirth during the pregnancy or within 6 weeks after the end of pregnancy (WHO, 2013). It is reflected by number of maternal deaths during a given year per 100,000 live births in a population, known as maternal mortality ratio (MMR). A live birth is the birth of a child with any sign of life, excluding stillbirths. Severe maternal morbidity (SMM) is taken by the US Centers for Disease Control and Prevention (CDC) as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health”. The International Classification of Diseases (ICD), Revision 10 (WHO, 1992) defines maternal death as death of a pregnant woman or death within 42 days of the termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Thus, maternal deaths are more specific and form a subset of pregnancy-related deaths.
Related concepts are
and can be taken as the probability of a woman (typically for the age group 15 – 49 years) dying from maternal causes during the course of her reproductive lifespan. It describes risk of maternal death per pregnancy or per birth in a population. Wilmoth (2009) found MM Rate based on age range as more stable than MM Ratio.
Lifetime risk of maternal mortality indicates the cumulative loss of life due to maternal deaths over the female life course. While the MM Ratio and the MM Rate are in terms of frequency of maternal death in relation to the number of live births or to the female population of reproductive age, Lifetime risk based on maternal deaths over the female life course is preferred as a summary measure of impact of maternal mortality. However, lifetime risk of death due to maternal causes can be calculated in various ways. The method used to estimate Lifetime risk in the 2000 UN overestimated by 20% (approx.) and a different method was adopted in 2005 UN estimates (WHO 2007). Despite desirability of computation of lifetime risk using age-specific data, use of either MM Ratio or MM Rate computed for ages 15–49 years are common for international comparisons, due to non-availability of reliable age-specific data. It was computed by indicating probability of at least one woman in reproductive age will die due to child birth or puerperium assuming that chance of death is uniformly distributed across the entire reproductive span. A woman’s lifetime risk of maternal death was recorded as 1 in 5,400 in high income countries and 1 in 45 in lowincome countries (WHO 2019). MMR, MM Rate and Life Time Risk registered by India during 2018-20 were 97, 6.0 and 0.21% respectively. Details can be found in https://censusindia.gov.in/
Reduced MMR is one of the critical measures to show progress in improving maternal health. Maternal morbidity covers short-term or long-term health problems resulting from pregnancy and/or giving birth (CDC, 2021). Clearly, it has negative outcomes to the woman’s well-being (Firoz et al. 2013). If maternal deaths are the tips, maternal morbidity is the base. Discrepancies exist concerning definition of maternal morbidity. Need for a measurable definition for consistent measurement and monitoring of maternal morbidity covering risks of mother, fetus, or both across space and time was felt (Vanderkruik et al. 2013). Chakhtoura et al. (2019) listed the following factors which increase women’s risk for maternal morbidity and mortality:
- Existing or pre-pregnancy health conditions, such as cardiovascular disease, obesity, asthma, or a compromised immune system
- Older maternal age.
- Lifestyle factors, such as current or former smoker
- Having twins, triplets, or other multiples
- Pregnancy complications:
- Preeclampsia, a spike in blood pressure after the 20th week of pregnancy, increases a woman’s risk for high blood pressure, blot clots, and stroke later in life (Bellamy et al. 2007).
- Women with gestational diabetes, high blood sugar during pregnancy, are at higher lifetime risk for diabetes (usually type 2) and for fatty liver disease and first-time mothers having normal deliveries run higher risk for pelvic floor disorders. (NICHD. 2019).
- Vaginal birth after cesarean (VBAC) is considered as safe for some women, but women having VBAC run higher risk for rupture of the uterus, leading to infection, bleeding, and other problems (American College of Obstetricians and Gynecologists, 2017)
- Racial, ethnic, and socioeconomic backgrounds. Disparities in the rates of maternal deaths of black women and American Indian/Alaska Native women in the United States were observed.
While maternal ill-health is socio-economic problems, maternal mortality is socio-economic tragedy. Reduced maternal mortality implies better reproductive health of women. Thus, reduction of maternal mortality and the promotion of maternal health and wellbeing are the vital needs of all countries of the world.
1.2 The Sustainable Development Goal 3 (SDG 3) to be achieved by 2030 include among others:
3.1 Reduction of global maternal mortality ratio (MMR) to less than 70 per 100,000 live births.
3.2 End preventable deaths of newborns and children under 5 years of age, implying reduction of neonatal mortality to at least 12 per 1,000 live births and under-5 mortality to at least 25 per 1,000 live births.
At the global level, MMR declined to 223 per 100,000 live births in 2020 from 339 in 2000 (WHO 2023). However, opposite trends are also there. For example, maternal mortality in US increased to death of 1205 women due to maternal causes in 2021 against 861 in 2020 and 754 in 2019 (Hoyert, 2023). Reduction of global MMR in 2020 translates to occurrence of maternal death every two minutes in 2020 and recording of about 800 deaths of women from preventable causes related to pregnancy and childbirth on each day of 2020 (WHO 2024). The year 2020 saw maximum maternal deaths (70%) in sub-Saharan Africa, followed by Central and Southern Asia. Fifteen year-old girls in sub-Saharan Africa had the highest lifetime risk (1 in 40) which is about 400 times the risk recorded in Australia and New Zealand. Global MMR in 2020 at the level of 223 per 100,000 live births, need annual reduction @ 11.6% to achieve the target of MMR of less than 70 by 2030. Annual rate of reduction of 11.6% has rarely been achieved at the national level.
MMR in India declined consistently from 130 per lakh live births in 2014-16 to 97 in 2018-20 primarily due to various healthcare initiatives and quality maternal and reproductive care initiated by the Govt. of India. Eight states of India which have already achieved the target 3.1 of SDG 3 are: Kerala (19), followed by Maharashtra (33), Telangana (43), Andhra Pradesh (45), Tamil Nadu (54), Jharkhand (56), Gujarat (57) and Karnataka (69). Continuation of the trend of reduction of MMR in India providing respectful maternal care will help the country to achieve the SDG target of MMR less than 70 well before the stipulated time of 2030.
Significant health inequities are there at the global level. As per the Global Burden of Disease Study, = 19 (Kassebaum et al. 2013).
The risks of maternal death in India were highest in rural and tribal areas of north-eastern and northern states, even after adjustment for education and other variables and reducing the MMR from 398/100,000 live births in 1997–98 to 97/100,000 in 2018-20(Meh et al. 2022). Thus, effect of MMR on health and economic outcomes needs further attentions to implement and monitor well co-ordinated efforts towards reduction of maternal mortality and morbidity.
The paper describes major factors of maternal mortality and morbidity and their effects on socio –economic and demographic aspects along with practical implications in India even it achieves the SDG target 3.1 of MMR= 70 per 100000, implying need to go beyond SDG 3.1. The research is of an inductive type that depicts results through the review of the bibliography and observation methods regarding factors of Maternal mortality and morbidity and its consequences.
Literature survey
Based on distribution of MMR across the countries and time, Souza et al. (2024) argued that maternal deaths could be prevented by proper manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. Poor maternal health is related with diminished child health, neonatal survival, cognitive development, child behavior, school performance, productivity, etc. (Almond et al. 2012; Martorell, 2010). Improved maternal nutrition benefits economic development through improved human capital and also improving health of the future generations (Onarheim et al. 2016).
Deaths of mothers during delivery affect the surviving children. Cumulative probability of children surviving up to 10 years was 0.24 for children whose mothers died (Ronsmans et al. 2010). For children who lost their mothers within 42 days of their birth, relative risk of dying within the first 1–6 months of the child’s life was 35.5 (Nguyen et al. 2019). Infant mortality rate for India declined to 2.18 deaths per thousand live births in 2020 against 5.52 deaths per thousand live births in 1971.
Children born from teenage pregnancies had poor health outcomes, life satisfaction, educational achievement, personal income later in life, etc. (Lipman et al. 2011; Poudel et al. 2022). If teenaged mothers could delay their pregnancies, attained higher education and been employed, the opportunity costs could be 1% (China) to 30% (Uganda) of GDP (Chaaban & Cunningham, 2011). The 4th National Family Health Survey estimated 11.8 million teenage pregnancies in India in 2006 (IIPS, 2007). In India, 25% of women in the age group 15-29 are married before reaching 18 years, the minimum legal age of marriage.
Time interval between successive pregnancies less than 6 months, between 6 to 17 months, and greater than 59 months gave rise to greater risk of adverse pregnancy outcomes (Conde-Agudelo et al. 2006). Risk of infant mortality got increased when inter-pregnancy intervals are short (DaVanzo et al. 2008). Short inter-pregnancy interval (IPI) is a well-known risk factor for preterm births and low birth weights. Kannaujiya et al. (2023) found inter-pregnancy interval (IPI) of 12–17 months are risk factors for stunting and underweight among children under 5 in India and increasing birth spacing may improve child health outcomes in India.
Major causes contributing to maternal death, in addition to risks attributable to pregnancy and childbirth are: poor-quality care from health services, income levels and place of doweling (Khan et al. 2006). Meh et al. (2022) suggested that the quality of emergency obstetric care is a major driver of maternal mortality. The leading cause of maternal death in India was obstetric haemorrhage (Montgomery et al. 2014).
Maternal death and morbidity is much higher for C-sections than with vaginal deliveries, primarily due to higher risk of hemorrhage and sepsis in C-sections. For such mothers, the risk increases in subsequent pregnancies cumulatively (Kotaska, 2015).
Kirigia et al. (2006) estimated the loss in GDP attributable to maternal mortality in the WHO African Region and found a statistically significant negative effect of maternal mortality on GDP where each maternal death decreased per capita GDP by US$ 0.36 per year. Societies that prioritize women's health are likely to have better population health overall, and will remain more productive for generations to come (Onarheim et al.2016).
Traditional gender roles of childbearing, complications from pregnancy and delivery predispose women for absence from work and prevent them from joining the labour market (World Bank, 2012). Women in U. S. could engage them both in paid work and in motherhood duties, due to lower value of maternal mortality and access to high-quality infant formula.
Maternal education helps to improve child survival since educated mothers know effective ways to prevent, recognize and treat childhood diseases (Majumder and Islam,1993) and thus, reduces risks of childhood mortality independent of other risk factors (Oliveira et al. 2007).
Family planning enables women to have better-planned pregnancies and healthier babies. Access to birth control can reduce the likelihood of young maternal age at first birth, increase the number of women participating in formal labour force, raise the number of annual hours worked by women (Bailey, 2006) and accelerate the reduction in birth rates (Bailey, 2010).
Increasing institutional deliveries implying giving birth to a child in a medical institution under the overall supervision of trained and competent health personnel is a step towards reduction of maternal mortality. In India, institutional deliveries has increased from 79 % in 2015-16 to 89 % in 2019-20 due to various steps taken by the Government of India to promote institutional deliveries, such as operationalisation of Sub-Centres, Primary Health Centres, Community Health Centres and District Hospitals for providing 24x7 basic and comprehensive obstetric care, along with capacity building of healthcare providers in basic and comprehensive obstetric care to for high quality services during childbirth at the institutions
(https://censusindia.gov.in/nada/index.php/catalog/44379).
Socioeconomic factors not only influence maternal death but also help to design effective health and hospital policies (Maine, 2001). Jeong et al. (2020) undertook log-binomial regression model to find empirical association between maternal mortality and income-level adjusted covariates and found that women from rural areas with lower income levels, delivered via cesarean section, and having maternal comorbidities run higher risk of maternal death; similarly among women who lived in large or small cities, with low income level and history of C-sections or maternal comorbidities had higher risk of maternal death in comparison to those belonging to high income category. The study suggested interventions to alleviate the risk of maternal death along with improvement of quality of childbirth care in vulnerable group to alleviate the risk of maternal death.
Regarding SDG target 3.2, India adopted India Newborn Action Plan (INAP) in 2014 as her committed response to the Global Every Newborn Action Plan (ENAP). INAP with a number of Strategic Intervention Packages aims at accelerating the reduction of preventable newborn deaths and stillbirths in the country, with the goal of attaining ‘Single Digit Neo-natal Mortality Rate (NMR)’ and ‘Single Digit Still Birth Rate (SBR)’ by 2030. Currently, neo-natal deaths per year are estimated as 7.47 lakh which is expected to decline to below 2.28 lakh annually by 2030, once the goal is achieved. List of intervention packages are: Pre-Conception and Antenatal Care, Care during Labour and Child birth, Immediate Newborn Care, Care of Healthy Newborn, Care of Small and Sick Newborn and Care beyond Newborn Survival.
Socio-economic effects
India has made appreciable progress in improving maternal mortality and morbidity and Neo-natal Mortality Rate but, has a long way to go further to minimize health problems of mothers and newborns resulting from factors like malnutrition, poverty, illiteracy, unhygienic living conditions, infections and unregulated fertility, ineffective public health services for obstetric care, etc. Factors of maternal health along with insufficient income and poor education constitute an interconnected web of economic, social, cultural issues and a vicious cycle of inadequate healthcare access, increasing the risks faced by poor women (Wamala et al. 2023).
Based on ratios of maternal to stillbirth and neonatal mortality, Boerma et al. (2023) identified five phases of transitions from highest mortality (phase-1) to lowest mortality (phase-5) covering maternal, stillbirth and neonatal mortality. However, the spectrum of the transition is intuitive. Moreover, the authors observed that almost all countries that transited from phase 1 to phase 2 and early phase 3primarily due to shift from home-delivery to institutional delivery.
In a developing country like India, a mother’s death is much more than an emotional crisis, often leading to long-term social and economic breakdown, both for her immediate family and the wider community. Aged surviving boys may leave schools and for many poor girls, early marriage and early motherhood are the available viable options. School dropouts and early marriages tend to renew poverty cycle for the next generation affecting the society and the economy. Ripple effects of maternal deaths may even include hard-pressed fathers sending the children to live with other families with likelihood of further damaging family integrity.
Exact ascertainment of the situation could be monitored with the availability of number of maternal deaths as per medical as well as socio cultural causes. Meh et al. (2022) estimated the absolute number of maternal deaths in India using UN Population Division 2019 estimates for deaths of women aged 15–49 years. Mari Bhat (2002) updated estimates of maternal deaths for India and its major states. However, procedures used in such estimations suffer from limitations.
Rough estimates
The birth rate in India in 2023 was 16.949 live births per 1000 people against 17.163 in 2022. With the birth of over 16 million children each year India accounts for nearly one fifth of the world's annual child births. In India, more girl babies die than boy babies. The gender differential in child survival is currently 11 per cent.
Total population as of May 2024 is 1,440,221,916, based on interpolation of the latest United Nations data.
Population in the age group 15 to 49: 67.8%
Total number of live births per year is (0.678 *1.44 billion) = 16.09 million
If MMR is taken as 70 per 100,000 live births, then number of maternal deaths per year is
* 16.09 million = 11261 i.e. at least 11261 Indian families will be motherless in a year due to pregnancies which affect the surviving children. The estimate assumed no growth of population and thus, is a lower estimate.
Considering cumulative probability of children surviving up to 10 years as 0.24 for children whose mothers died (Ronsmans et al. 2010), India is likely to lose (1- 0.24) * 11261 = 8558 children in the next 10 years.
Female Labour Force participation
In addition, annual maternal deaths of 11261 per year will affect female labour force participation rate (FLFPR). Data from the Periodic Labour Force Survey (2022-23) indicates that FLFPR in India is at 37 percent, an increase of 4.2 percentage points from the last survey (2021-22). Annual maternal deaths of11261 implies disturbance in Indian labour force as 0.37*11261= 4166 ladies are no more available in the working age population (WAP) in a year implying significant loss of income of 4166 Indian families resulting in acute hardships, reduced savings, pushing poor or marginal households further into poverty and significant contraction of consumption which in turn affect the economy in general. These are in addition to loss of govt. taxes from the earnings of 11261 working ladies.
India enjoys tremendous demographic dividend since percentage share of working-age population (between 19 – 60 years) exceeded the combined share of children and elderly population since 2018 and increasing economic growth rate in terms of GDP. However, achieving MMR of 70 per 100000 implying loss of at least 11261 ladies per year from the working-age population disturbs the mid-bulging shape of age-structure of India. Other causes of death of young females and mortality rate of young males create further problem to maintain the desired structure. In 2021, the mortality rate for men was at 253.83 per 1,000 male adults in India and the same for women was at 185.91 per 1,000 female adults (including maternal deaths).
Declining trend of birth rate coupled with high rate of child death may disturb to achieve the desired rate of inflows from child population (0 to 18 years) to working-age population. Thus, continuation of MMR of 70 per 100000 live births without arresting deaths of adults and children translates into socioeconomic and demographic loss to India.
Discussion
Benefits of health outweigh the cost since healthy people forms the foundation of healthy societies and economies. Reduction of maternal mortality is associated with increases in life expectancy, universal health coverage, skilled birth attendance, antenatal care coverage, and the human development index. The neonatal mortality rate shows a strong correlation with maternal mortality, suggesting that this indicator is most probably a product of similar determinants. Similarly, health-system indicators, such as universal health coverage and skilled birth attendance, tend to correlate strongly with maternal mortality levels, demonstrating the crucial role of health systems in safeguarding maternal health against external forces. In contrast, the less strong correlations between other social indicators (e.g., Gini index that measures national income or wealth distribution) and maternal mortality suggests that the relationship is more distant, possibly indirect, or mediated by other factors.
Illustrative measures to stop/reduce maternal deaths and closely linked newborn health in urban and rural areas are:
- Prevent unintended pregnancies including teenage pregnancies by providing easy access to contraception, safe abortion services and quality post-abortion care.
- Ensure that each adult woman gets access to contraception, safe abortion services, and quality post-abortion care.
- Provide quality care in pregnancy and after childbirth by skilled health professionals, as timely management and treatment can make the difference between life and death for the mothers and the newborns.
- Other policy measures including income, access to education across race and ethnicity that may put sub-populations at greater risk, harmful gender inequalities resulting in low prioritization of the rights of women towards safe, quality and affordable sexual and reproductive health services.
- Promoting health and wellbeing across the life course.
Implement universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Conclusions
India in particular and other developing countries in general need to go beyond the SDG target of MMR of 70 per 100000 live births to enjoy socioeconomic and demographic benefits. Integrated policies and implementation to arrest the factors of maternal health keeping in mind that insufficient income and poor education constitute an interconnected web of economic, social, cultural issues and a vicious cycle of inadequate healthcare access, increasing the risks faced by poor women. Future studies may be undertaken to find the net birth rate which ensures that working-age population is 55% +.
Highlights
- Determinants of maternal mortality and morbidity described
- Provides rough estimates of socioeconomic and demographic effects in India even it achieves the SDG target 3.1
- Achievement of SDG target 3.1 alone without arresting deaths of adults and children translates into socioeconomic and demographic loss to India
India in particular and other developing countries in general need to go beyond the SDG target of MMR of 70 per 100000 live births to enjoy socioeconomic and demographic benefits.
