This presentation explains about trends in Maternal Mortality in India during the period 1911-2013 and also future estimates of decline in MMR in selected states to achieve UN SDG goals. Life time risk has been calculated and states have been ranked. By fitting polynomial regression equation, the MMR has been projected for the next decade and estimated time required to decline less than 90.

1. Trends in Maternal Mortality
1911-2013
Prof.C.P.Prakasam
prakasamcp60@gmail.com
Former Professor,
International Institute for Population Sciences,
Mumbai,India
3 September 2021 Measures of Maternal Mortality--
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2. To know about:
 Definition of Maternal Mortality
 Measurement of Maternal Mortality (rate, ratio)
 Sources of Maternal Mortality data in India
 Examples
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Maternal Mortality Definition
 According to the Tenth Revision of the
International Classification of Diseases (ICD-10),
the maternal death is defined as:
WHO defines Maternal Mortality as deaths
during pregnancy, childbirth, or within 42
days of termination of pregnancy,
irrespective of the duration and site of the
pregnancy, for a specified year. (WHO, 1993).
 A pregnancy-related death, therefore, is determined solely by
timing of death relative to pregnancy, childbirth, and the
postpartum period. A true maternal death requires specific cause of
death information.

4. Measures of MMR
 To measure the maternal mortality four
important indicators are used.
 1. Maternal Mortality Ratio (MMRatio),
 2. Maternal Mortality rate (MMR),
3.Proportion maternal and
 4. Life time risk (LTR) due to maternal
mortality.
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5. 1.Maternal Mortality ratio (MMRatio)
 Maternal Mortality ratio is defined as:
Number of maternal deaths X 100,000
Number of live births
 The denominator is number of live births and
maternal mortality ratio is measuring
obstetric risk.
 The MMRatio overestimates obstetric risk by
excluding from the denominator pregnancies
which do not terminate in to live birth. As the
MMRatio is not age standardized measure, the
ratio across the countries is not comparable.
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6. Maternal Mortality Rate (MMR)
 Maternal Mortality Rate (MMR)is defined as
Number of Maternal Deaths X 1000
Number of women aged 15-49
 The Maternal Mortality Rate is an indicator of
the risk of maternal deaths among women
of reproductive age. It is equivalent to a
cause-specific death rate because the
woman in the denominator is exposed for the
risk of maternal death.
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7. MMR
 The relation between MMRatio and MMR is:
MMRatio = MMR
General Fertility Rate
General Fertility Rate (GFR)=
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Objectives
 To understand the levels and trends in Maternal
Mortality in selected states in India (1911-2013)
Approach:
 To examine the Life time risk by states.
 To understand the Levels of MMR, Normalize the
states and examine the ranks over 15 years.
 To estimate future MMR, by using regression
method.
 To identify the indicators influencing MMR across
the states

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Sources of Maternal Mortality Data
 There are various sources available (Recently)
for measuring maternal mortality:
--------
 Civil Registration System,
 Hospital Records
 Household surveys NFHS,DLHS,AHS
 Census
 Reproductive Age Mortality Studies (RAMOS)
 Methods are :Direct or Indirect according to the
Data Source.

10. Limitation of Data Source
 Measuring maternal mortality depends upon
accuracy of data and requires large sample
as the incidence of maternal deaths are very
low.
 Civil registration systems has limited
coverage and not accurate in India.
 Hospital records have limited to hospital
death and pregnancies. Maternal deaths
occurred outside hospital is not included in
calculation of maternal deaths.
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11. Data Source for the present study
 The Office of the Registrar General of India
(ORGI) under the Ministry of Home Affairs,
Government of India provides estimates of
MMR- using demographic data Collected
through the Sample Registration System
(SRS).
 In order to enhance the SRS sample size,
and get robust estimates, the MMR
estimates are derived by pooling 3 years data
to yield reliable estimates.
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12. SRS Reports
 The first Report on maternal mortality in
India (1997-2003) –Trends, Causes and Risk
Factors released in October, 2006
 The special bulletin on Maternal Mortality in
India (2004-2006) released in 2009
 The special bulletin on Maternal Mortality in
India (2007-2009) released in 2011.
 This special bulletin is the third in the series
of Maternal Mortality (2010-12) and the latest
estimates are available for 2011-13.
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13. Fig:1: Trends in MMR in India and selected states 1997-2013
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398
327
301
254
212
178 167
520
461
438
375
308
257 246
187
206
173
149
127
105 93
184
229
199
174
149
127
115
0
100
200
300
400
500
600
1997-98 1999-01 2001-03 2004-06 2007-09 2010-12 2011-13
India EAG and Assam Southern States other states

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Table -1: Trends in maternal mortality ratio (MMR)* in selected Major states in India : 1997-2013.
India & Bigger States Period
1997-98 1999-01 2001-03 2004-06 2007-09 2010-12 2011-13
INDIA TOTAL 398 327 301 254 212 178 167
Assam 568 398 490 480 390 328 300
Bihar/Jharkhand 531 400 371 312 261 219 208
Madhya Pradesh/ Chhattisgarh 441 407 379 335 269 230 221
Orissa 346 424 358 303 258 235 222
Rajasthan 508 501 445 388 318 255 244
Uttar Pradesh/ Uttaranchal 606 539 517 440 359 292 285
EAG AND ASSAM SUBTOTAL 520 461 438 375 308 257 246
Andhra Pradesh 197 220 195 154 134 110 92
Karnataka 245 266 228 213 178 144 133
Kerala 150 149 110 95 81 66 61
Tamil Nadu 131 167 134 111 97 90 79
SOUTH SUBTOTAL 187 206 173 149 127 105 93
Gujarat 146 202 172 160 148 122 112
Haryana 136 176 162 186 153 146 127
Maharashtra 166 169 149 130 104 87 68
Punjab 280 177 178 192 172 155 141
West Bengal 303 218 194 141 145 117 113
Other 300 276 235 206 160 136 126
OTHER SUBTOTAL 184 229 199 174 149 127 115
*MMR measures number of women aged 15-49 years dying due to maternal causes per 1,00,000 live births.

15. Trends
 In southern states (Andhra Pradesh
Karnataka , Kerala , and Tamil Nadu the
MMR declined 187 during 1997-98 to 93
during 2013.
 In EAG states (Assam ,Bihar /Jharkhand ,MP
/ Chhattisgarh , Orissa and Rajasthan) MMR
declined from 520 in 1997-98 to 246 in 2011-
13.
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16. Trends…
 Among all the states MMR is low in Kerala
(61), Maharashtra (68), Tamil Nadu (79), and
Andhra Pradesh (92).
 Highest MMR in Assam followed by Uttar
Pradesh/Uttaranchal
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17. MMR by states 1997-98, 2011-13
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0 200 400 600 800
Tamil Nadu
Haryana
Gujarat
Kerala
Maharashtra
Andhra Pradesh
Karnataka
Punjab
Other
West Bengal
Orissa
INDIA TOTAL
M.P/…
Rajasthan
Bihar/Jharkhand
Assam
U.P/Uttaranchal
131
136
146
150
166
197
245
280
300
303
346
398
441
508
531
568
606
0 50 100 150 200 250 300
Kerala
Maharashtra
Tamil Nadu
Andhra Pradesh
Gujarat
West Bengal
Other
Haryana
Karnataka
Punjab
INDIA TOTAL
Bihar/Jharkhand
M.P/ Chhattisgarh
Orissa
Rajasthan
U.P/Uttaranchal
Assam
61
68
79
92
112
113
126
127
133
141
167
208
221
222
244
285
300

18. Table:2 : Relative rank of Maternal Mortality Ratio (MMR)
in Indian states : 1997-2013
 Relative Rank:
Minimum is Kerala State during 1997-2013
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Table:2 : Relative rank of Maternal Mortality Ratio (MMR) in Indian states : 1997-2013
1997 1999 2001 2004 2007 2010 2011
State Rank Rank Rank Rank Rank Rank Rank
Kerala 4 1 1 1 1 1 1
Maharashtra 5 3 3 3 3 2 2
Tamil Nadu 1 2 2 2 2 3 3
Andhra Pradesh 6 8 8 5 4 4 4
Gujarat 3 6 5 6 6 6 5
West Bengal 9 7 7 4 5 5 6
Haryana 2 4 4 7 7 8 7
Karnataka 7 9 9 9 9 7 8
Punjab 8 5 6 8 8 9 9
Bihar/Jharkhand 13 11 11 11 11 10 10
M.P/ Chhattisgarh 11 12 12 12 12 11 11
Orissa 10 13 10 10 10 12 12
Rajasthan 12 14 13 13 13 13 13
U.P/Uttaranchal 15 15 15 14 14 14 14
Assam 14 10 14 15 15 15 15

20. Life time risk
 The life time risk is defined as the probability
that at least one women of reproductive
age(15-49) will die due to child birth or
puerperium assuming that chance of death is
uniformly distributed across the entire
reproductive span and has been worked out
using the following formula:
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21. Life time risk=
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Table 3:Lifetime Risk of MMR 2007-09 (%) 2010-12 (%)
INDIA TOTAL 0.6 0.4
1 Assam 1.0 0.8
2 Bihar/Jharkhand 1.0 0.8
3 Madhya Pradesh/ Chhattisgarh 1.0 0.7
4 Orissa 0.7 0.6
5 Rajasthan 1.2 0.9
6 Uttar Pradesh/Uttaranchal 1.4 1.0
EAG AND ASSAM SUBTOTAL 1.1 0.8
7 Andhra Pradesh 0.3 0.2
8 Karnataka 0.4 0.3
9 Kerala 0.1 0.1
10 Tamil Nadu 0.2 0.2
SOUTH SUBTOTAL 0.3 0.2
11 Gujarat 0.4 0.3
12 Haryana 0.5 0.4
13 Maharashtra 0.2 0.2
14 Punjab 0.4 0.3
15 West Bengal 0.3 0.2
OTHER SUBTOTAL 0.4 0.3

23. Age distribution of Maternal Deaths
Maternal Deaths
7
39
27
17
7
2 1
0
5
10
15
20
25
30
35
40
45
2008-10
2010-12
Non Maternal Deaths
0
5
10
15
20
15-19
20-24
25-29
30-34
35-39
40-44
45-49
12
16
13
12 12
15
19
2008-10
2010-12
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Table 4: State Regression Equation R2 Type of
Equation
MMR=90
Kerala y = -51.1ln(x) + 164.0 R² = 0.916 Log
Maharashtra y = -17.96x + 196.5 R² = 0.966 Linear
Tamil Nadu y = -1.030x4 + 18.20x3 - 110.7x2 +
251.3x - 25.85
R² = 0.987 Poly 4th
Andhra
Pradesh
y = 3.064x3 - 36.02x2 + 103.0x + 128.6 R² = 0.985 Poly 3rd
Gujarat y = -3.690x2 + 19.31x + 148.2 R² = 0.737 Quadratic
West Bengal y = 5.940x2 - 76.84x + 364.4 R² = 0.970 Quadratic
Haryana y = -4.452x2 + 32.19x + 115.4 R² = 0.743 Quadratic
Karnataka y = -22.5x + 291 R² = 0.918 Linear
Punjab y = 1.670x4 - 29.81x3 + 184.7x2 -
470.1x + 592.7
R² = 0.991 Poly 4th
INDIA TOTAL y = -38.57x + 416.7 R² = 0.971 Linear
Bihar/Jharkhan
d
y = -51.46x + 534.7 R² = 0.935 Linear 16-18 years
M.P/
Chhattisgarh
y = -40.14x + 486.5 R² = 0.977 Linear 20-22 years
Orissa y = -1.799x4 + 33.37x3 - 213.1x2 +
501.3x + 28
R² = 0.992 Poly 4th 22-24 years
Rajasthan y = -50.39x + 581.4 R² = 0.970 Linear 20-22 years
U.P/Uttaranchal y = -57.67x + 664.7 R² = 0.975 Linear 21-23 years
Assam y = -2.033x5 + 45.52x4 - 382.0x3 +
1466.x2 - 2514x + 1954
R² = 0.999 Poly 5th 22-24 years

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150 149
110
95
81
66 61
y = -51.17ln(x) + 164.03
R² = 0.916
0
20
40
60
80
100
120
140
160
180
1997-98 1999-01 2001-03 2004-06 2007-09 2010-12 2011-13
Kerala
Kerala
Log. (Kerala )
131
167
134
111
97
90
79
y = -1.0303x4 + 18.207x3 - 110.75x2 + 251.37x - 25.857
R² = 0.9878
-20
0
20
40
60
80
100
120
140
160
180
1 2 3 4 5 6 7 8
Tamil Nadu
Tamil Nadu
Poly. (Tamil Nadu )
Poly. (Tamil Nadu )

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346
424
358
303
258
235 222
y = -1.7992x4 + 33.371x3 - 213.13x2 + 501.35x + 28
R² = 0.9922
0
50
100
150
200
250
300
350
400
450
1 2 3 4 5 6 7
Orissa
Orissa
Poly. (Orissa )
606
539 517
440
359
292 285
y = -57.679x + 664.71
R² = 0.9752
0
100
200
300
400
500
600
700
1 2 3 4 5 6 7
U.P/Uttaranchal
U.P/Uttaranchal
Linear (U.P/Uttaranchal)

27. Estimated Trend in MMR in Bihar
531
400
371
312
261
219 208
y = -51.46x + 534.7
R² = 0.935
0
100
200
300
400
500
600
1997 1999 2001 2004 2007 2010 2011
Bihar
Bihar
Linear (Bihar)
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Table:5 : Estimated Number of years required to reach MMR=90 in EAG
States from 2013
State Regression R² Type of
Equ
Number of
Years
required
Bihar/Jharkhand y = -51.46x + 534.7 R² =
0.935
Linear 16-18 years
M.P/ Chhattisgarh y = -40.14x + 486.5 R² =
0.977
Linear 20-22 years
Orissa y = -1.799x4 + 33.37x3 -
213.1x2 + 501.3x + 28
R² =
0.992
Poly
4th
22-24 years
Rajasthan y = -50.39x + 581.4 R² =
0.970
Linear 20-22 years
U.P/Uttaranchal y = -57.67x + 664.7 R² =
0.975
Linear 21-23 years
Assam y = -2.033x5 + 45.52x4 -
382.0x3 + 1466.x2 -
2514x + 1954
R² =
0.999
Poly
5th
22-24 years

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Table:6 : Causes of Maternal Mortality (WHO)-ICDS-10
Cause of death Number and % of
deaths
Possibly preventable: %
and no.
Haemorrhage 127 000 25% 55% 70 000
Sepsis 76 000 15% 75% 57 000
Preeclampsia/
Eclampsia
64 000 12% 65% 42 000
Obstructed
labour
38 000 8% 80% 30 000
Unsafe abortion 67 000 13% 75% 50 000
Other direct
causes
39 000 8% --- ---
Indirect causes 100 000 20% 20% 20 000
TOTAL 510 000 100

30. Preventable due Health Programs
 Haemorrhage may arise at any time during
pregnancy, birth and puerperium. Acute
bleeding will commence before or between
routine antenatal care visits. Major separation of
the placenta is life-threatening, because of acute
blood loss and later coagulopathy.
 Puerperal sepsis is mainly due to unclean home
deliveries, higher rates of pathogenic genital
tract infections and poor cleanliness and delay
after rupture of the membranes
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31. Program Indicators
 Mother who had received any ANC (%)
 Mother who had 3 or more ANC (%)
 Mother who had full ANC Checkup (%)
 Institutional Delivery (%)
 Safe Delivery (%)
 IFA Tablets consumed (100) days
 Mothers who received PNC within 2 weeks of
delivery (%)
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Table: 7: Correlation between Indicators and Maternal Mortality in Selected
States (2013-15)
Indicators influencing Maternal mortality
Maternal
Mortality
( r )
1 Mother received first trimester check-up ANC -.335
2 Mother received 3 or more ANC -.759**
3 IFA tablets Consumed (100) -.604*
4 Mother received Full ANC -.673*
5 PNC within 2 weeks of delivery -.309
6 Institutional deliveries -.487
7
Births assisted by doctor/nurse/LHV/ANM/other health
personnel (%)
-.429

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Conclusions
 From the above SRS data analysis it was
evident that
 MMR declined in all selected Indian States during
1977 to 2013 period.
 Steep decline in MMR observed in EAG states
and slow decline in Southern states.
 Future years decline in MMR will be observed in
Tamil Nadu, Andhra Pradesh and Maharashtra
than in Kerala State.
 To achieve further decline in MMR, special efforts
to be made in reducing MMR in EAG states more
specially in Assam, Uttar Pradesh/Uttaranchal
along with other EAG states.

34. Conclusions…..
 To reach MMR=90, with the prevailing
conditions, EAG states requires 20 to 22
years from hence.
 To observe decline in MMR in EAG states,
effective health programs to be introduced to
have maximum coverage in ANC , PNC and
Institutional Deliveries .
 Among the southern states Kerala State
achieved maximum decline in MMR. Special
medical attentions should be provided to
Pregnant mothers.
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35. Conclusions…..
 Maternal Mortality is negatively correlated
with Mother received 3 or more ANC, IFA
tablets Consumed (100),Mother received
Full ANC.
 In selected states % of mothers with Full
ANC and consumed IFA tablets will have
less Maternal Mortality than other states.
THANK YOU
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