Estimates and Correlates of District-Level Maternal Mortality Ratio in India
Authors: Goli Srinivas , Puri Parul , Salve Pradeep S. , Pallikadavath Saseendran , James K.S. 
Published: September 2021

ABSTRACTDespite the progress achieved, approximately one-quarter of all maternal deaths worldwide occur in India. Till now, India monitors maternal mortality in 18 out of its 36 provinces using information from the periodic sample registration system (SRS). The country does not have reliable routine information on maternal deaths for smaller states and districts. And, this has been a major hurdle in local-level health policy and planning to prevent avoidable maternal deaths. For the first time, using triangulation of routine records of maternal deaths under Health Management Information System (HMIS), Census of India, and SRS, we provide Maternal Mortality Ratio (MMR) for all states and districts of India. Also, we examined socio-demographic and health care correlates of MMR using large-sample and robust statistical tools. The findings suggest that 70% of districts (448 out of 640 districts) in India have reported MMR above 70 deaths-a target set under Sustainable Development Goal-3. According to SRS, only Assam shows MMR more than 200, while our assessment based on HMIS suggests that about 6-states (and two union territory) and 128-districts have MMR above 200. Thus, the findings highlight the presence of spatial heterogeneity in MMR across districts in the country, with spatial clustering of high MMR in North-eastern, Eastern, and Central regions and low MMR in the Southern and Western regions. Even the better-off states such as Kerala, Tamil Nadu, Andhra Pradesh, Karnataka, and Gujarat have districts of medium-to-high MMR. In order of their importance, fertility levels, the sex ratio at birth, health infrastructure, years of schooling, post-natal care, maternal age and nutrition, and poor economic status have emerged as the significant correlates of MMR. In conclusion, we show that HMIS is a reliable, cost-effective, and routine source of information for monitoring maternal mortality ratio in India and its states and districts.Key questionsWhat is already known?Despite the progress achieved, approximately one-quarter of all maternal deaths worldwide occur in India.Maternal mortality prevalence is highly heterogeneous across the major provinces of India.So far country monitors maternal mortality in 18 out of 36 states using information from the periodic sample registration system (SRS).Clinical and socio-demographical reasons for maternal mortality have been studied using hospital-based studies and micro-level qualitative studies.What are the new findings?For the first time, the study provides maternal mortality ratio (MMR) estimates for all states and districts of India.The findings suggest that 70% of districts (448 out of 640 districts) in India have reported MMR above 70 deaths per 1000 live births—a target set under Sustainable Development Goal-3.According to SRS, only Assam shows MMR of more than 200, while our estimates based on HMIS suggest that 6 states (and two union territory) and 128 districts demonstrate MMR above 200.The findings highlight the presence of spatial heterogeneity among districts in the country, with spatial clustering of high MMR in North-eastern, Eastern, and Central regions; and low MMR in the Southern and Western regions. We have also observed considerable within-state variations—across districts.Using a larger sample and robust statistical process, the study documents socio-demographic and health care correlates of MMR across the districts of India.What do the new findings imply?Findings help in identifying ‘hot spots’ within the states and key socio-demographic and health care correlates of maternal mortality, thus assisting in micro-level maternal health care policy and planning.Availability of health infrastructure, access to affordable and quality maternal health care, especially in districts with high fertility, low education, and economically poor are key pathways to reduce maternal mortality in India.A significant association between sex ratio at birth and MMR suggest that, maternal deaths are also happening due to unsafe abortions, thus this needs policy attention.HMIS is a reliable, cost-effective, and routine source for monitoring progress in the reduction of avoidable maternal mortality in India and its states and districts.