Maternal Mortality Ratio: Tracking Risks of Childbirth-Related Deaths

Every two minutes, somewhere in the world, a woman loses her life because of complications related to pregnancy or childbirth. Most of these deaths are preventable. The Maternal Mortality Ratio, or MMR, is the single most important indicator we use to measure how safe – or unsafe – it is to bring a child into the world. It tells us not just about medical risk, but about the strength of a country’s healthcare system, the status of women, and the gaps that still exist between rural and urban India.

What is the Maternal Mortality Ratio? 🔗

The Maternal Mortality Ratio is defined as the number of maternal deaths per 100,000 live births in a given year. According to the World Health Organization, a maternal death is the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management – but not from accidental or incidental causes.

Three key time windows matter here: pregnancy itself, childbirth, and the puerperium – the 42-day (six-week) recovery period after delivery. Many people assume that once a baby is delivered safely, the danger is over. In reality, a large share of maternal deaths occurs in the puerperium, often due to bleeding, infection, or undetected complications that develop after the woman returns home.

MMR vs MMRate: Two related but different measures 🔗

Students often confuse the Maternal Mortality Ratio with the Maternal Mortality Rate, and the textbook shorthand MMR/MMRT does not help. They are not the same thing.

The Maternal Mortality Ratio (MMR) uses live births as the denominator. It captures the obstetric risk per pregnancy that ends in a live birth. The Maternal Mortality Rate (MMRate), on the other hand, uses person-years lived by women of reproductive age (15-49 years) as the denominator. As explained in a review published in Current Medicine Research and Practice, the rate reflects both the risk of dying during pregnancy and the frequency with which women in a population become pregnant. The ratio is more useful for comparing the safety of childbirth between countries; the rate is more useful for understanding the overall burden on women of reproductive age.

How is MMR calculated? 🔗

The formula is straightforward:

MMR = (Number of maternal deaths in a year / Number of live births in the same year) × 100,000

If a state recorded 2,000 maternal deaths and 1,000,000 live births in a year, the MMR would be 200 per 100,000 live births. The multiplier of 100,000 is used because maternal deaths are, fortunately, rare enough that smaller denominators would produce inconveniently small decimals.

The numerator looks simple but is the hardest part to measure. A maternal death must be correctly identified as maternal – that is, caused by or aggravated by pregnancy. Deaths are usually grouped into two categories. Direct obstetric deaths arise from complications of pregnancy, labour, or the puerperium itself, such as puerperal sepsis (a severe infection of the reproductive tract after childbirth), postpartum haemorrhage, obstructed labour, or eclampsia. Indirect obstetric deaths result from a pre-existing condition – such as anaemia, heart disease, tuberculosis, or diabetes – that is worsened by the physiological stress of pregnancy.

The role of puerperal infections 🔗

Puerperal infection deserves a closer look because it remains a stubborn contributor to maternal deaths in low- and middle-income settings. The infection enters the uterus during or shortly after delivery and can quickly progress to sepsis. A systematic review applying the WHO ICD-MM classification reports that pregnancy-related infection accounts for roughly 5% of maternal deaths globally, while obstetric haemorrhage and hypertensive disorders account for about 18% and 14% respectively. In India, a study using verbal autopsy data from the Million Death Study found that obstetric haemorrhage was the leading cause of maternal deaths, with the highest burden in Bihar, Uttar Pradesh, and Uttarakhand.

Many of these deaths are preventable with clean delivery practices, timely antibiotics, and skilled birth attendance – which is precisely why MMR is treated as a sensitive indicator of healthcare quality.

Where does Indian data come from? 🔗

Counting maternal deaths in a country of 1.4 billion people is not easy. India relies primarily on the Sample Registration System (SRS), a large-scale demographic survey run by the Office of the Registrar General. The SRS uses a dual-record system: part-time enumerators record births and deaths in sample areas every month, and full-time supervisors independently verify these events every six months. When a woman of reproductive age dies, a post-death verbal autopsy is conducted by interviewing relatives, and two physicians independently review the report to assign a cause.

The SRS Maternal Mortality Bulletin is the official source for India’s MMR figures. Other supporting datasets include the National Family Health Survey (NFHS), the Health Management Information System (HMIS), and global modelled estimates from the UN Maternal Mortality Estimation Inter-agency Group (UN-MMEIG).

Where the numbers stand today 🔗

India’s progress over the last three decades has been remarkable. According to the Press Information Bureau release based on the UN-MMEIG Report 2000-2023, India’s MMR has declined by 86% over the past 33 years – far ahead of the global reduction of 48% over the same period. The SRS Bulletin for 2019-21 placed India’s MMR at 93 per lakh live births, down from 130 in 2014-16. More recent estimates suggest the figure has fallen further: a 2025 review in the Journal of Family Medicine and Primary Care notes the national MMR is now around 97 per 100,000 live births, and the latest SRS data shows that in 2023, 88 women died of maternal causes for every 100,000 live births – roughly 22,500 deaths in a single year.

Regional disparities, however, remain stark. Kerala and Andhra Pradesh report MMR figures as low as 30 – lower than the Maldives or Thailand – while states in the Empowered Action Group (Bihar, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, and others) plus Assam continue to lag well behind the national average.

Why MMR matters as a policy indicator 🔗

MMR is not just a number; it is a mirror held up to the entire health system. A high MMR usually signals problems far beyond the delivery room: weak antenatal care, late referrals, poor transport, shortage of skilled birth attendants, low female literacy, child marriage, anaemia, and out-of-pocket health spending.

This is why MMR is enshrined as a key indicator under Sustainable Development Goal 3.1, which commits all countries to reducing the global MMR to fewer than 70 deaths per 100,000 live births by 2030. India has set an even more ambitious target of bringing its MMR below 70 well before that deadline.

How India is trying to bring MMR down 🔗

The decline in MMR has been driven largely by a cluster of national programmes operating under the National Health Mission. Janani Suraksha Yojana (JSY), launched in 2005, provides conditional cash transfers to encourage poor women to deliver in health facilities; it has benefited over 11 crore women. Janani Shishu Suraksha Karyakram (JSSK) guarantees free institutional delivery – including caesarean section – along with free transport, diagnostics, medicines, and diet. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), launched in 2016, provides free, fixed-day antenatal checkups by specialists on the 9th of every month at government facilities.

Other initiatives include LaQshya, which focuses on improving the quality of care inside labour rooms; SUMAN (Surakshit Matritva Aashwasan), which guarantees respectful, zero-cost maternity care; Pradhan Mantri Matru Vandana Yojana (PMMVY), which provides cash benefits to pregnant and lactating women; and the Maternal Death Surveillance and Response (MDSR) system, which was introduced in 2017 to systematically review every maternal death and identify preventable factors.

The remaining challenges 🔗

Despite this progress, an analysis of district-level data published in a peer-reviewed journal found that 70% of India’s districts – 448 out of 640 – still report an MMR above the SDG target of 70. The deaths are concentrated in rural pockets of poorer states where women have fewer antenatal visits, lower rates of skilled birth attendance, and weaker access to emergency obstetric care.

Three classic delays continue to cost lives: the delay in deciding to seek care, the delay in reaching a health facility, and the delay in receiving adequate care once at the facility. Bringing MMR down further will depend less on building new schemes and more on closing these last-mile gaps – strengthening referral transport, training skilled birth attendants, ensuring blood availability in district hospitals, and addressing the social determinants like anaemia, early marriage, and women’s autonomy.

Reading MMR critically 🔗

As a student of population studies, it helps to remember that MMR has limits. It captures only deaths up to 42 days after pregnancy ends, so deaths from late maternal causes – between 43 days and one year – are missed unless reported separately. It also depends on the quality of vital registration, and in regions where many births and deaths go unrecorded, MMR estimates can substantially undercount the true burden.

Even so, MMR remains one of the most powerful summary measures we have. A falling MMR usually means that women are reaching skilled care in time, that institutional deliveries are rising, and that the system is catching complications before they turn fatal. A stagnant or rising MMR is an early warning that something – whether infrastructure, training, or equity – is breaking down.

What do you think? If two Indian states have similar per capita incomes but very different MMR values, what factors beyond income would you investigate first to explain the gap? And do you think a single national MMR figure is meaningful for a country as diverse as India, or should policy be driven entirely by district-level numbers?

References

1. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622
2. https://journals.lww.com/cmre/fulltext/2024/14060/maternal_mortality__india_s_trajectory_to.1.aspx
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10683107/
4. https://www.dataforindia.com/maternal-mortality/
5. https://censusindia.gov.in/census.website/data/SRSMMB
6. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2128024
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC12178503/
8. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(24)00560-6/fulltext
9. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2118786
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC10021851/