Decadal trends of maternal mortality and utilization of maternal health care services in India: Evidence from nationally representative data

ABSTRACT

Introduction:

The Sustainable Development Goals (SDGs) aim to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100,000 live births by 2030. In India, the MMR has significantly declined over the years and currently stands at 97 per 100,000 live births. Despite this achievement, accurately estimating maternal mortality remains a challenge, mainly because of incomplete records of maternal deaths and their causes. This study aims to review national trends in maternal mortality, using data from the Sample Registration System (SRS) and National Family Health Survey (NFHS). Additionally, it explores the relationship between improvements in the utilization of maternal healthcare services and their impact on reducing maternal mortality.

Material and Methods:

The study examines trends in maternal mortality using nationally available datasets such as the SRS, NFHS, National Sample Survey, and government administrative records. These publicly available sources provide insight into maternal healthcare utilization patterns over time. Key indicators analyzed include antenatal care (four or more visits), skilled birth attendance, and postnatal care utilization. Additionally, secondary sources like the World Health Report were reviewed for historical context.

Results:

India has achieved a remarkable decline in MMR over the past three decades, dropping from 570 maternal deaths per 100,000 live births in 1990 to 103 in 2019–2020 and further to 97 in 2023. Historically, the MMR was much higher, with 1,287 maternal deaths per 100,000 live births recorded in 1957. The following decades witnessed a steady reduction: 1,355 in 1960, 892 in 1970, 437 in 1991, 327 in 2000, 212 in 2009, and 130 in 2015. A recent decline of 8.8% was observed between 2016 and 2018 (MMR: 113) and 2020 (MMR: 103). Concurrently, maternal healthcare utilization demonstrated significant improvement, with upward trends in antenatal care, institutional deliveries, and postnatal care across the country.

Conclusion:

The consistent decline in India’s MMR is because of improvements in socioeconomic conditions, healthcare infrastructure, and public health initiatives such as Janani Suraksha Yojana and Pradhan Mantri Surakshit Matritva Abhiyan. Enhanced transport networks, mobile communication, and rural infrastructure have improved access to maternal care, while grassroots workers such as Accredited Social Health Activists have strengthened antenatal and postnatal service delivery. However, direct obstetric causes like hemorrhage, infection, and sepsis still significantly contribute to maternal deaths. Achieving the SDG target of 70 maternal deaths per 100,000 live births by 2030 requires addressing regional disparities, strengthening health systems, and overcoming resource constraints. Closing gaps in maternal healthcare utilization and fostering collaboration among stakeholders is critical for implementing sustainable and equitable health reforms.

Introduction

In developing countries such as India, complications during pregnancy and childbirth continue to be leading causes of mortality and disability among women of reproductive age. Maternal mortality serves as a critical indicator of healthcare delivery and utilization. Efforts to address this issue were emphasized under the Millennium Development Goal 5, which aimed to reduce the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015. Building on this, the Sustainable Development Goals (SDGs) set an ambitious target to reduce the global MMR to below 70 per 100,000 live births by 2030.[1,2,3,4] India, accounting for 8.3% of global maternal deaths in 2020, is among the ten countries contributing to 60% of these fatalities worldwide. The estimated number of highest global maternal deaths in 2020 have been reported from Nigeria (28.5%), India (8.3%), the Democratic Republic of the Congo (7.5%), and Ethiopia (3.6%).[3] Despite this, significant progress has been made, with India’s MMR dropping from 384 per 100,000 live births in 2000 to 103 in 2020.[5,6] This decline, at an annual reduction rate of 6.36%, outpaces the global reduction rate of 2.07% during the same period. While India’s National Health Policy 2017 set a target of achieving an MMR of 100 by 2020, eight states—Kerala (19), Maharashtra (33), Telangana (43), Andhra Pradesh (45), Tamil Nadu (54), Jharkhand (56), Gujarat (57), and Karnataka (69)—have already surpassed the SDG target.[4,6,7]

The lack of reliable data often hinders accurate estimates of maternal mortality in India. Population-based surveys, such as the Sample Registration System (SRS) and National Family Health Survey (NFHS), play a pivotal role in tracking these trends.[8] There are many sources of data to estimate maternal mortality, such as - Vital Registration, Sample Vital Registration, Reproductive Age Mortality Studies, District level household and facility surveys, National population censuses, Facility-based studies, Statistical Models (UNICEF/UNFPA/WHO/World Bank estimates), etc.[9,10,11,12,13 ] These surveys utilize diverse methods, including vital registration, facility-based studies, and statistical modeling, to overcome challenges in capturing maternal deaths comprehensively. The need for various survey methods for estimating MMR stems from the complexity of accurately capturing maternal deaths. The Survey Methods of data collection are often used in combination to improve the accuracy and reliability of estimates.

The SRS, conducted by the Office of the Registrar General, India, is a large-scale demographic survey that provides annual estimates of various fertility and mortality indicators at national and sub-national levels. It is operational in 8847 sample units (4,961 rural and 3,886 urban). It combines continuous enumeration of births and deaths with independent retrospective surveys for data validation, covering over 8 million people across urban and rural areas.[14] Similarly, the NFHS is a nationwide household survey providing insights into maternal mortality trends and healthcare utilization. The first two NFHS rounds reported MMRs of 424 (1992–1993) and 540 (1998–1999). To date, five NFHS rounds have been conducted, offering valuable data for assessing the effectiveness of maternal healthcare interventions.[1,2,15,16,17]

This study examines the trends in maternal mortality across various data sources and evaluates the impact of maternal healthcare utilization, with a focus on understanding the effectiveness of interventions based on NFHS data. In this study, we evaluate national and subnational level trends of maternal mortality and health care service utilization over a decade in India by examining the nationally representative data i.e., SRS and NFHS. This study can provide valuable insights and benefits across various stakeholders such as researchers, practitioners, patients and policy-makers. Researchers, practitioners, and policymakers can utilize the findings of the study to improve maternal and child health care by improving their ante-natal care (ANC) and post-natal care (PNC) services. Improved service delivery ensures more personalized care for pregnant women, reducing the risks of maternal and infant morbidity and mortality.

Materials and Methods

The present study utilized two nationally representative survey datasets available in the public domain: all five rounds of the NFHS, conducted during the following periods: NFHS-1 in 1992–93, NFHS-2 in 1998–99, NFHS-3 in 2005–06, NFHS-4 in 2015–16, and NFHS-5 from 2019–21, as well as data from the SRS. The NFHS is India’s demographic and health survey, providing consistent and reliable estimates of fertility, mortality, family planning, maternal and child healthcare service utilization, and other related indicators at both national and state levels. During each survey round, NFHS administered three types of questionnaires: the Household Questionnaire, the Woman’s Questionnaire, and the Village Questionnaire. Each round is nationally representative, covering over 99% of India’s population. NFHS-1 (1992–93) included data from 88,562 households and 89,777 ever-married women aged 13–49 from urban and rural areas across 24 states and union territories. NFHS-2 (1998–99) surveyed 92,486 households and 90,303 ever-married women aged 15–49 across 26 states. NFHS-3 (2005–06) included all 29 states, collecting data from 109,401 households and 124,385 women aged 15–49 (both married and unmarried). NFHS-4 (2015–16) expanded to all 36 states, gathering information from 601,509 households and 699,686 women aged 15–49 (married and unmarried). NFHS-5 (2019–21) continued this trend, covering all 36 states and union territories, with data from approximately 641,000 households and around 724,000 women aged 15–49 (both married and unmarried). A sample of 242055 women, consisting of 90,000 women, 124,385 women, 190,898 women, and 176,877 women aged 15–49 who had experienced a pregnancy in the last five years, has been taken from NFHS-1 (1998–99), NFHS-2 (1998–99), NFHS-3 (2005–06), NFHS-4 (2015–16), and NFHS-5 (2019–21), respectively, and will be analyzed in this study. Detailed descriptions of the NFHS survey design and findings are available in various reports at the national and state levels. These materials can be accessed from the Demographic Health Survey Program’s data - www.DHSprogram.com.[1,2,15,16,17] Furthermore, secondary data on antenatal care, postnatal care, and maternal mortality will be triangulated from all five rounds of NFHS. The sampling methodologies and instruments employed in these surveys ensure the representativeness of the data, enabling robust analyses of maternal healthcare utilization and maternal mortality trends across India. The SRS is an ongoing demographic survey conducted by the Registrar General of India since 1971, providing birth and death estimates at both national and state levels. The bulletins of SRS data can be accessed from the https://censusindia.gov.in website. The sample sizes reflect the representativeness of the survey data and enable inferences about maternal health indicators in India.

Explanatory variables are as follows:-

1. Antenatal and Intra-natal Care Indicators:

   • Early antenatal care initiation

   • Mothers with at least three or more antenatal care visits

   • Institutional deliveries

   • Births attended by skilled personnel

   • Iron and folic acid supplementation (100 days)

   • Tetanus toxoid vaccination during pregnancy

   • Home births conducted by skilled health personnel

   • Cesarean section deliveries by type of healthcare facility (public/private)

2. Postnatal Care Indicators:

   • Mothers who received postnatal care from qualified health personnel within two days of delivery.

3. Maternal Mortality: Data from SRS bulletins and all rounds of NFHS will be triangulated to track trends in MMRs and rates across various periods.

Data analysis

The study involves descriptive statistical analysis and trend analysis using secondary data from SRS and NFHS. Triangulation of data from different sources will be performed to provide comprehensive insights into input, process, and outcome indicators that contributed to changes in maternal mortality rates over time.

The analysis is structured as follows:

• Input Indicators: Health services, infrastructure, and preventive interventions.

• Output/Outcome Indicators: Service utilization (antenatal care, delivery, and postnatal care).

• Impact Indicators: Trends in maternal mortality and morbidity, as measured by MMR and related indicators.

Ethical considerations

The study is secondary data analysis, ethical approval is not required.

Expected outcomes

This study is expected to identify the key factors contributing to the reduction in maternal mortality in India, highlighting the impact of public health interventions, and identifying areas where further improvements are necessary to meet national and global targets for maternal health.

Results

Results shown in Table 1 represent the MMR estimates per 100,000 live births in India from various sources. Table 2 shows the trends of MMR, maternal mortality rate, and lifetime risk according to the SRS from 2007 to 2021. Table 3 represents the State/UT-wise MMR per the SRS for the last five years. Table 4 shows the demographic profile (such as Age, Place of residence, Marriage and fertility, Family Planning, Unmet need for family planning, Nutritional Status of Ever-Married Adults (age 15–49), Anaemia among Women, Knowledge of HIV/AIDS among Ever-Married Adults (age 15–49), and Women’s Empowerment) the according to the five round of NFHS (1 to 5). Table 5 represents trends of maternal health indicators as per all five rounds of NFHS. Table 6 shows the percentage receiving information on specific signs of pregnancy complications such as vaginal bleeding, convulsions, prolonged labor, severe abdominal pain, and high blood pressure, and whether they were told about the signs of pregnancy complications and where to go if they experienced any of these signs; according to the various rounds of NFHS. Table 7 summarizes the key insights from NFHS-4, NFHS-5, and SRS data (2019) regarding maternal healthcare service utilization, disparities, and barriers and also points out areas for future research and program evaluations.

Table 1.

Estimates of maternal mortality ratio per 100,000 live births in India

Source of Data	Reference year	Maternal mortality ratio
NSS, 14th Round	1957	1,287
NSS,19th Round	1963-1964	1,174
SRS	1972-1976	892
SRS	1977-1981	844
SRS	1982-1986	568
NFHS-1	1992-1993	437
1997-1998 retrospective MMR surveys	1997-1998	398
SRS	1997	407
SRS	1998	406
NFHS 2	1998-1999	540
SRSprospective household reports	1999-2001	327
SRS special survey of death using RHIME	2001-2003	301
SRS	2004-2006	254
SRS	2007-2009	212
SRS	2010-2012	178
SRS	2011-2013	167
SRS	2014-2016	130
SRS	2016-2018	122
SRS	2017-2019	113
The Office of the Registrar General of India released the bulletin on MMR on March 14, 2022	2017-19	103

Source: NFHS - National Family Health Survey; NSS - National Sample Survey; RHIME - Routine, representative, re-sampled household interview of mortality with a medical evaluation, a method used in SRS; SRS - Sample Registration System

Table 2.

Trends of maternal mortality ratio, maternal mortality rate and life time risk

Year	Maternal Mortality Ratio	Maternal mortality rate	Life Time Risk
2007-09	212	16.3	0.6%
2010-12	178	12.4	0.4%
2011-13	167	11.7	0.4%
2014-16	130	8.8	0.3%
2015-17	122	8.1	0.3%
2016-18	113	7.3	0.3%
2017-19	103	6.5	0.2%
2019-21	97	6.0	0.2%

Source: SRS Special Bulletin on MMR

Table 3.

State/UT wise Maternal Mortality Ratio (MMR) for last five years

	SRS 2015-17 S	SRS 2016-18	SRS 2017-19	SRS 2018-20
Assam	229	215	205	195
Madhya Pradesh	188	173	163	173
Uttar Pradesh	216	197	167	167
Chhattisgarh	141	159	160	137
Odisha	168	150	136	119
Bihar	165	149	130	118
Rajasthan	186	164	141	113
Haryana	98	91	96	110
Punjab	122	129	114	105
West Bengal	94	98	109	103
Uttarakhand	89	99	101	103
Karnataka	97	92	83	69
Gujarat	87	75	70	57
Jharkhand	76	71	61	56
Tamil Nadu	63	60	58	54
Andhra Pradesh	74	65	58	45
Telangana	76	63	56	43
Maharashtra	55	46	38	33
Kerala	42	43	30	19
Other States	96	85	77	77
India	122	113	103	97

(*Source: RGI: Special Bulletin on MMR)

Table 4.

Demographic profile, marriage and fertility, family welfare, nutrition, knowledge of HIV/AIDS and women’s empowerment among ever-married women (age 15-49), NFHS rounds

Variables	NFHS-1 (1998-99)	NFHS-2 (1992-93)	NFHS-3 (2005-06)	NFHS-4 (2015-2016)	NFHS -5 (2019-2020)
No. of Households in Sample	88562	91196	109041	568200	636,699
Number of Women	242055	89,199	124385	699,686	724,115
Number of Women in Rural area	NA	61,337	67,424	494,951	544,580
Number of Women in Urban area	NA	27,862	56,961	204,735	179,535
Marriage and Fertility:
1. Women age 20-24 married by age 18 (%)	54.2	50.0	47.4	26.8	23.3
2. Total Fertility Rate (Children per woman)	3.4	2.9	2.7	2.2	2.0
3. Women aged 15-19 who were already mothers or pregnant at the time of the survey (%)	NA	NA	16.0	7.9	6.8
4. The median age at first birth for women aged 25-49 (%)	19.4	19.3	19.8	21.0	21.2
Family Planning (currently married women, age 15-49):
Current use of any method (%)	40.7	48.2	56.3	53.5	66.7
Unmet need for family planning
Total unmet need	19.5	15.8	12.8	12.9	9.4
Nutritional Status of Ever-Married Adults (age 15-49):
1. Women whose Body Mass Index is below normal (%)	NA	36.2	33.0	22.9	18.7
2. Women who are overweight or obese (%)	NA	10.6	14.8	20.6	24.0
Anemia among Women:
Ever-married women age 15-49 who are anemic (%)	NA	51.8	56.2	53.2	57.2
Pregnant women age 15-49 who are anemic (%)	NA	49.7	57.9	50.4	52.2
Ever-married men age 15-49 who are anemic (%)	NA	NA	24.3	22.7	25.0
Knowledge of HIV/AIDS among Ever-Married Adults (age 15-49):
Women who have heard of AIDS (%)	NA	40.3	57.0	76	97
Women with knowledge that the consistent condom use can reduce the chances of getting HIV/AIDS (%)	NA	NA	34.7	20.9	21.6
Women’s Empowerment :
Currently married women who participate in household decisions (%)	NA	NA	36.7	84.0	88.7
The ever-married women who have ever experienced spousal violence (%)	NA	NA	37.2	31.2	29.3

Source: NFHS all rounds

Table 5.

Trends of maternal health indicators, five rounds of NFHS

Indicator	NFHS 1 (1992-1993)	NFHS 2 (1998-1999)	NFHS 3 (2005-2006)	NFHS 4 (2015-2016)	NFHS 5 (2019-2020)
The mothers who had no antenatal check-up (%)	32.0	34.0	22.8	16.5	06
The mothers who had an antenatal check-up in the first trimester (%)	24.9	33.1	43.9	58.6	70.0
The mothers who had at least three antenatal care visits (%)	44	44	51	13.4	15.7
The mothers who had at least four antenatal care visits (%)	NA	NA	37.0	51.2	58.5
Mothers who had full Antenatal care (%)	NA	NA	11.6	21	31.2
Received two or more TT injections (%)	58	66.8	76.3	83.0	83.1
Took an intestinal parasite drug (%)	NA	NA	3.8	18.0	31.1
Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within two days of delivery (%)	NA	NA	36.8	62.4	78.0
Institutional births (%)	26	34	38.7	78.9	88.6
Domiciliary deliveries	74	66	61.3	21.1	11.4
Pregnant women with anemia	NA	50	58	50.4	52.2
Deliveries conducted by health personnel	35	42	48	81.4	89.4
Caesarean Section Deliveries (%)	2.5	7.1	8.5	17.2	21.5
The births in a private health facility that were delivered by cesarean section (%)	12.3	24.6	27.9	40.9	47.4
The births in a public health facility that were delivered by cesarean section (%)	7.2	15.7	15.2	11.9	14.3
Mothers received postnatal care within two months of delivery	NA	16.5	42	NA	83.2
Mothers who received postnatal care within two days of delivery (%)	NA	14.2	36.8	62.4	81.7
Mothers who received no postnatal care (%)		NA	57.6	30.2	16.0
Mother’s who consumed IFA for 90 days or more when they were pregnant with their last child (%)	NA	47.5 (3 months)	23.1	NA	NA
The pregnant women who consumed 100 or more IFA tablets/syrup equivalent (%)	NA	NA	15.2	30.3	44.1
The pregnant women who consumed IFA tablets/syrup equivalent for 180 days (%)	NA	NA	NA	NA	26.0
The mothers who consumed iron folic acid for 180 days or more when they were pregnant (%)	NA	NA	NA	14.4	26.0

1 Based on the last birth to ever-married women in the three years preceding the survey. 2 Based on the last two births to ever-married women in the three years preceding the survey. 3 Doctor, auxiliary nurse midwife, nurse, lady health visitor, or other health personnel

Table 6.

The percentage receiving information on specific signs of pregnancy complications, five

Variables	NFHS-1 (1998-99)	NFHS-2 (1992-93)	NFHS-3 (2005-06)	NFHS-4 (2015-2016)	NFHS -5 (2019-2020)
Vaginal bleeding	N	11.0	16.6	46.0	60.8
Convulsions	NA	NA	15.4	44.0	60.3
Prolonged labour	NA	NA	20.1	50.1	65.7
Severe Abdominal Pain	NA	NA	NA	51.8	67.5
High Blood Pressure	NA	NA	NA	51.6	67.3
Whether they were told about the signs of pregnancy complications & where to go if thry experienced any of these signs	NA	NA	41.1	67.2	80.4

Table 7.

Summarization of the key insights regarding maternal health care service utilization, disparities, barriers, future research and program evaluations from nationally representative data

Indicator	NFHS 4 (2015-16)	NFHS 5 (2019-20)	SRS Data (2019)
Health Care Service Utilization	- Increase in institutional births (78.9%)	- Further rise in institutional births (88.6%)	- Institutional births: 87.0%.
	- 51.2% received 4+ANC visits	- 58.5% received 4+ANC visits	- 52.0% received 4+ANC visits.
	- 62.4% received postnatal care within 2 days	- 78% received postnatal care within 2 days	- 56.2% received postnatal care within 2 days.
Disparities in Maternal Health Care Service Utilization	- Rural areas lag in institutional births and ANC	- Reduced disparities but rural areas still behind	- Significant rural-urban gap in institutional births.
	- Regional differences in ANC uptake	- Urban-rural gap in institutional deliveries	- Variation in ANC across states.
Social Determinants of Health in Relation to ANC	- Education positively correlated with ANC visits	- Women’s empowerment linked to better ANC outcomes	- Education and income influence ANC utilization.
	- Wealth and urban residence are strong predictors	- Caste and poverty still major barriers	- Lower utilization among poorer households.
Barriers to Utilizing Ante Natal Care Services	- Lack of education and awareness	- Cost, transportation, and cultural barriers	- Distance to facility and socio-cultural beliefs.
	- Distance from health facilities	- Limited availability of skilled personnel	- Shortage of trained health workers in rural areas.
Improved Maternal Health Outcomes	- Decline in maternal mortality	- Further reduction in maternal mortality	- Maternal mortality rate: 113 per 100,000 live births.
	- Reduced anemia among mothers	- Continued decline in maternal anemia	- Anemia prevalence among pregnant women remains high.
Identify Research Gaps and Areas Needing more Exploration	- Impact of ANC on long-term maternal health	- Research on quality of care during ANC visits	- Need for more localized studies on maternal health.
	- Regional disparities in maternal care utilization	- Sociocultural factors affecting ANC access	- Examine maternal health in context of urbanization.
Informing Future Research Directions	- Investigate influence of women’s autonomy on care	- Examine role of health infrastructure	- Study integration of health services.
	- Explore tailored interventions for marginalized	- Investigate impact of digital health initiatives	- Assess community health programs.
Evaluating Existing Maternal Health Programs	- Need for program improvements in rural areas	- Need for better integration of services	- Evaluation of maternal health programs needed.
	- Evaluate effectiveness of community health workers	- Review of institutional delivery quality	- Assess community-based interventions.

Source: NFHS and SRS

The results shown in Figure 1 show the trends of MMR according to the data of the NFHS rounds. Figure 2 represents the Comparative analysis of the Maternal Mortality and Antenatal Visits over various rounds of NFHS: Figure 2 shows that as the number of mothers who had at least three or more antenatal care visits (%) increased, maternal mortality steadily declined. These results indicated that the government executed the initiatives and incentives given to ASHA workers and mothers under schemes such as JSY and JSSK, and the schemes were well accepted by the community. Figure 3 shows a comparative analysis of Maternal Mortality and Postnatal Visits. The figure shows that the mothers who had received postnatal care from any healthcare provider within two days of delivery (%) led to a steady decline in maternal mortality. Figure 4 shows the MMR represented by large bars in the main graph with circles marking data points. The top left inset shows the lifetime risk as a percentage and the top right inset depicts the maternal mortality rate per thousand women.

Figure 1.

Figure shows the trends of Maternal mortality ratio (MMR) according to the data of the NFHS rounds: Maternal mortality gradually decreased over the years with good quality of timely care provided to women over the years

Figure 2.

Figure represents the Comparative analysis of the Maternal Mortality and Antenatal Visits overvarious rounds of NFHS

Figure 3.

Comparative analysis of the Maternal Mortality and Postnatal Visits: The figure below shows that the mothers who had received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within two days of delivery (%) decreased the maternal mortality steadily declined

Figure 4.

The figure shows the maternal mortality ratio represented by large bars in the main graph with circles marking data points. The top left inset shows the lifetime risk (LTR) as a percentage and top right inset depicts the maternal mortality rate per thousand women

Discussion

Maternal health is a crucial component of a country’s development, as it contributes to increasing equity and addressing broader social challenges such as poverty reduction. Under the National Health Mission, significant strategic investments have been made to improve maternal health. In 1990, India had an alarmingly high MMR of 570 women dying during childbirth for every 100,000 live births. Each year, around 138,000 women die due to complications related to pregnancy and childbirth. In contrast, the global MMR in 1990 was much lower, at 385. Since then, India’s MMR has decreased to 167 (from 2011 to 2013), compared to a worldwide MMR of 216 (in 2015). According to the publication “Trends in Maternal Mortality: 1990 to 2015,” India’s MMR has dropped by 68.7%, from 556 in 1990 to 139 in 2015, reflecting an average annual decline of 4.6%. India’s share of global maternal deaths has also reduced significantly, accounting for about 15%, as reported by the Maternal Mortality Estimation Inter-Agency Group.[6] on maternity-related deaths can be found in reports from the SRS, which provides the MMR. Additionally, the NFHS data helps establish benchmarks and track the progress of various health indicators over time. Both NFHS-4 and NFHS-5 indicate overall improvements in maternal health outcomes, while the SRS offers context by presenting current maternal mortality rates.

The NFHS data assist in establishing benchmarks and tracking the progress of various health indicators over time. Information regarding pregnancy-related health issues should have been collected in NFHS-1.[15] In NFHS-2, the most commonly reported pregnancy-related health problems were excessive fatigue (43%), followed by anemia (27%), swelling of the legs, body, or face (26%), and blurred vision (22%).[16] Additionally, 14% reported experiencing convulsions not related to fever, and 12% reported night blindness. According to NFHS-3, the pregnancy-related health problems most frequently reported were excessive fatigue (48%) and swelling of the legs, body, or face (25%). The data indicated that 10% of mothers had convulsions not associated with fever, and 9% reported experiencing night blindness. Notably, the prevalence of vision problems and convulsions not related to fever was higher in rural areas compared to urban areas, whereas swelling of the legs, body, or face was more common in urban settings. In NFHS-4, for the most recent live births during 2015-16, the reported percentages of women experiencing specific pregnancy-related health problems included swelling of the legs, body, or face (31.8%), convulsions not from fever (16.5%), and difficulty with vision in daylight (10.9%). NFHS-5 highlighted a high incidence of pregnancy-induced hypertension and eclampsia, which continue to be significant causes of maternal mortality and morbidity.[1,2,17] The institutional deliveries have increased from 47% in 2007–08 to 78.9% in 2015–16 (NFHS-4) to 89% in 2019–21 (NFHS-5). Kerala has reported 100% institutional births. However, only 46% of the births in Nagaland were institutional births. Institutional deliveries are effective in reducing infant mortality rates.[1,2,17,18]

To bring pregnant women to health facilities to ensure safe delivery and emergency obstetric care, a demand generation scheme - Janani Suraksha Yojana (JSY), was launched in April 2005.[19] The utilization of public health infrastructure by pregnant women has increased significantly because of JSY and Janani Shishu Suraksha Karyakaram (JSSK).[20] High-quality antenatal care before the delivery is essential for a positive outcome. According to the WHO data during 2010–2016, 62% of women globally received 4 ANCs.[21] There has been a rise in the percentage of females who had antenatal check-ups in the first trimester from 33% in NFHS-1 to 70% in NFHS-5. This helps in the early identification of possible complications during pregnancy. The number of mothers with at least three or more antenatal visits has steadily increased. The numbers rose sharply from NFHS 2 to 3 and from NFHS 4 to 5.[22] Currently, 59% of our country’s mothers have adequate antenatal visits. The proportion of women in India who received ANC has risen from 77 percent in NFHS-3 (2005–06) to 84 percent in NFHS-4 (2015–16). In 2016–17, data shows that 92% of pregnant women received free drugs, 80% free diagnostics, 63% free diet, 70% free home-to-facility transport, while 64% received free drop back home after delivery.[23,24,25] Vaccination with tetanus toxoid during pregnancy helps prevent neonatal tetanus in newborns.[26] There is an increase in the number of pregnant mothers who receive TT from 55% in NFHS-1 to a promising 92% in NFHS-5.[15,17]

The number of pregnant women aged 15–49 years who are anemic (%) has increased over time from 49.7% in NFHS-2 to 52.2% in NFHS-5. Mothers who consume iron Folic Acid for 100 Days or more when pregnant must be strengthened and monitored. The NFHS data shows that less than half (44.1%) of expectant mothers consumed IFA for 100 days. To address the problem of anemia, the government has initiated the National Iron + Initiative; iron and folic acid supplementation are given at health facilities and during outreach activities to prevent anemia in pregnant and lactating women.

Compared to NFHS-1, 2, and 3, the NFHS-4 and 5 surveys indicate significant progress in maternal healthcare, particularly in the rise of births assisted by skilled birth attendants. The percentage of such births increased dramatically from 33% in NFHS-1 to 89.4% in NFHS-5.[27] The proportion of mothers receiving three or more antenatal care visits has also risen, accompanied by a steady decline in maternal mortality. These improvements suggest that initiatives and incentives provided to ASHA workers and mothers under programs such as the JSY and JSSK have been well-received and effectively implemented at the community level. Building on the success of the JSY scheme, the Government of India launched the JSSK on June 1, 2011, to provide free healthcare services to mothers and newborns, further enhancing maternal and child health.[28] In 2016, the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) was introduced by the Ministry of Health and Family Welfare (MoHFW), aiming to provide assured, free quality antenatal care to all pregnant women on the ninth day of every month. This initiative also encourages private healthcare providers to volunteer and offer specialist care in government facilities.[29] According to NFHS-5, however, only 3.2% of home deliveries are assisted by skilled birth attendants, highlighting the need for continued efforts to improve access to skilled care for all pregnant women, especially in rural and remote areas.[30,31] The data from the SRS further reinforces these trends. The SRS has reported a significant decline in maternal mortality over recent years, with the MMR dropping from 374 per 100,000 live births in 1997–1999 to 113 per 100,000 live births in 2016–2018. This decline reflects the positive impact of various maternal health programs, including JSY, JSSK, and PMSMA, which have increased institutional deliveries and improved the overall quality of maternal care. Moreover, the SRS data reveals that states with better implementation of these schemes, such as Kerala and Tamil Nadu, have shown remarkable reductions in MMR, further emphasizing the importance of regional-level interventions. These advancements reflect the success of ongoing policy initiatives.

Postnatal care provided by skilled attendants has significantly increased in recent years, with 78% of mothers now receiving postnatal care, a 16% rise from NFHS-4. NFHS-5 data further shows improvements: 71.6% of mothers received care within 48 hours of delivery (up from 64.3%), 84.1% within seven days (up from 76.6%), and 90.8% within six weeks (up from 82.2%). These gains are linked to a decline in maternal mortality, as timely postnatal visits help address complications such as infections and hemorrhage. Ongoing initiatives such as the JSSK have contributed to this progress. However, improving postnatal care quality, especially in rural areas, remains crucial for ensuring better outcomes for all mothers. The study by Mohanty and Srivastava examines inequalities in maternal healthcare utilization between NFHS-4 (2015–16) and NFHS-5 (2019–21). It identifies persistent disparities in access to antenatal care, skilled birth attendance, and institutional deliveries, primarily influenced by socioeconomic, regional, and demographic factors. The authors advocate for targeted interventions to address inequities and enhance maternal healthcare services in underserved areas.[32]

The Government of India has launched several initiatives to improve maternal and newborn care, including Surakshit Matratva Ashwasan and the Labour Room and Quality Improvement Initiative. These programs ensure women and newborns receive free, quality, and respectful care at public health facilities, with no denial of services, aiming to prevent avoidable maternal and newborn deaths. The Maternity Benefit Program also improves care during antenatal and postnatal periods.[33,34]

Digital solutions, especially mobile health tools (mHealth), are enhancing healthcare delivery by linking frontline workers to national systems, improving accountability, and collecting real-time data. Key initiatives include strengthening First Referral Units and Wellness Centers and setting up Maternal and Child Health Wings and Obstetric ICUs/HDUs at high-case-load facilities. Referral systems with emergency transport services and the distribution of MCP Cards and Safe Motherhood Booklets further support maternal health education. Programs such as the PMMVY, Mission Saksham Anganwadi, and Poshan 2.0 also promote maternal and child health.[35,36] These efforts, alongside improved antenatal and postnatal care, have contributed to a steady decline in maternal mortality, enhancing the quality of care for women and children.

The COVID-19 pandemic has substantially impacted and disrupted the delivery of essential Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH + N) services.[37] The recommendation to curb the pandemic restricts travel and urges people to stay home. Disruptions have occurred across various levels of healthcare delivery, affecting service utilization and accessibility. Thus, enforcement of these measures has posed unprecedented difficulties to lakhs of vulnerable women accessing health services. All the progress toward decreasing the MMR has to be revised and revamped. The need to ensure convergence among different stakeholders while structuring maternal health policies so that health reforms can be accomplished effectively at all levels of health care. Revising and enhancing maternal health policies through ongoing schemes (JSY, JSSK, and PMSMA) and addressing challenges posed by disruptions like the pandemic are crucial for further progress.

Limitations of the study

The following are the limitations of the study -

1. Differences in the questionnaire —The total number of questions canvassed in the four rounds of NFHS is 358, 335, 738 (including household, women, and men), and 979 (including household, women, men, and bio-marker questionnaire), respectively. Questions regarding antenatal and postnatal care have been asked in all rounds.

2. Factors have affected the quality of the investigators, and the surveys are as follows -

   • I) The increased length of a questionnaire adds to the burden on respondents and pushes more of them over the threshold beyond which they will no longer cooperate or provide good responses.

   • ii) Poor payment results in a more significant dropout rate among trained investigators.

   • iii) Assigning data collection to consult agencies with no prior capacity-building resulted in the survey becoming more of a money-making exercise rather than focusing on collecting good data.

3. The questionnaire for the NFHS-3 survey and beyond requires complete privacy for administering it.

4. The causes of maternal mortality have yet to be mentioned in these reports, so exact figures for causes accounting for maternal mortality cannot be given.

Future research directions

The institutional deliveries have improved, however, the rural and urban gap persists (urban: 94.8% and rural 85%) as reflected by the NFHS 5 data. The institutional deliveries among the tribal women have increased, but they remain lower than the national average (78.2%). There is a need for strengthening the system and reaching the last mile. There is limited post-natal care utilization in the rural areas. The area-specific gaps such as the role of private healthcare facilities in driving trends like rising C-sections need to be addressed. Quality of care, not just coverage, especially in antenatal, intranatal, and postnatal services has to be improved.

Continued efforts to address anemia, regional disparities, and postnatal care, coupled with the expansion of digital health solutions and quality assurance initiatives, are essential for sustained improvements in maternal health outcomes. Moreover, evaluating existing programs like PMMVY and integrating them with new initiatives will help achieve sustainable maternal health improvements, especially for vulnerable and marginalized groups.

Conclusion

This study has meticulously determined antenatal and postnatal care and the trend of maternal mortality by looking at the data provided by the different rounds of NFHS done. Progress has been made in reducing maternal morbidity and mortality. By examining the data of 5 rounds of NFHS, the most sensitive indicators are a percentage increase in full ANC, an increase in institutional deliveries, deliveries attended by skilled birth attendants, and ensuring postnatal care within 48 hours of delivery. We still need to address anemia in pregnant women as despite the increase in the percentage increase in IFA tablet consumption, the anemia status is almost static. Adolescent girls are to be focused on maintaining a continuum of care and ensuring adequate iron stores and normal Hemoglobin levels to counter the increased demand during pregnancy.

The government needs to address all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities by strengthening the community-, facility-, district- and national-level healthcare delivery system and policies. Strengthening the health systems to respond to the needs and priorities of adolescent girls and women will lead to a shift toward a life cycle approach and will mean a healthy community. This is ensured only by systematically looking at and addressing the gaps in obstetric care and fixing the accountability to improve the quality of care and equity.

Practical Applications of the Research Findings (Implication)

Increased antenatal care visits, particularly in the first trimester, are likely to increase institutional births and reduce maternal mortality and morbidity. Policies addressing maternal anemia (e.g., improved IFA supplementation) may decrease adverse birth outcomes, including the need for cesarean sections. Investigating the higher cesarean section rates in private facilities compared to public health settings may reveal inefficiencies or over-medicalization of deliveries, influencing future policy on childbirth practices.

Researchers can gain insights into trends in maternal mortality and healthcare utilization, enabling further studies. Targeted interventions can reduce disparities, especially among marginalized groups like tribal and rural women, by establishing culturally sensitive health centers and increasing ASHAs in underserved areas.[32] Identifying service delivery gaps (e.g., low ANC visits) supports the development of training programs for healthcare workers. Findings on the urban-rural divide can drive the expansion of telemedicine for ANC and postnatal care. These applications highlight the value of secondary data analysis in creating effective strategies to improve maternal health and reduce mortality in India.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.