A Systematic Review of the Economic, Social, and Structural Factors Influencing Maternal Mortality Rate (MMR) in India Between 2014-2024

Introduction

Maternal Mortality Rate (MMR) is a crucial indicator used to assess the quality of maternal healthcare in a country. It is defined as the number of female deaths from any cause connected to or aggravated by pregnancy or its management (excluding deaths due to accidental or incidental reasons). This can occur during pregnancy, childbirth or within 42 days of termination of pregnancy, regardless of the site or duration of the pregnancy and is expressed per 100,000 live births, for a specified timeframe.⁵¹ High MMR represents a substantial loss of life and reflects broader societal impacts, including economic and social consequences. India, like many countries with high MMR, registers only a small percentage of births, deaths, and vital events, particularly in high-risk regions like Uttar Pradesh, Assam, and tribal areas in northern states. Maternal deaths are often underreported, especially in remote rural areas, complicating efforts to fully understand the scope of the problem and implement effective interventions. Targeted interventions in these regions are essential to addressing the high maternal mortality rates and improving overall maternal health outcomes.¹

Literature review

A complex interplay of direct and indirect factors drives maternal mortality in India. Understanding these factors is crucial for developing effective strategies to reduce MMR.

Direct Causes of Maternal Mortality

Biological complications such as hemorrhage, anemia, and eclampsia, are direct causes of maternal death. These conditions are often preventable or manageable with timely medical intervention, but they remain significant contributors to maternal deaths in India.

Post-Partum Hemorrhage (PPH)

PPH is one leading but preventable causes of maternal mortality worldwide.⁶ It occurs due to excessive bleeding during childbirth or the postpartum period. The proportion of deaths from obstetric hemorrhage is notably higher in poorer states like Bihar, Uttar Pradesh, and Uttarakhand¹ indicating that severe anemia, delayed recognition, and management can aggravate postpartum bleeding.

Anemia

Anemia is a prevalent condition among pregnant women in India, often resulting from iron deficiency. It can lead to various complications, including multiple abortions, antepartum hemorrhage, cardiac failure, and pre-eclampsia.⁷ Anemia exacerbates the risk of PPH and other pregnancy-related complications, making it a significant factor in maternal mortality. ³⁴

Hypertensive disorders

Pregnant women with hypertension are at increased risk of pre-eclampsia and other maternal and fetal or neonatal complications, including death.^1,8 About 50,000 maternal deaths occur worldwide due to eclampsia every year, its incidence being highest in developing countries. Despite being a preventable complication, its incidence remains high in referral hospitals.²⁸

Indirect Causes of Maternal Mortality

In addition to the direct causes, indirect factors such as economic, social, and structural barriers play a crucial role in influencing maternal mortality rates in India. These factors often influence the direct drivers of maternal deaths by limiting access to health care and contributing to delays in seeking medical care.  

Economic factors

Poverty or economic status has a remarkable impact on maternal health and is a significant barrier to accessing quality healthcare in India. ⁹ Poverty often forces women to deliver at home without any medical assistance, increasing the risk of complications during childbirth. Approximately half of the deliveries in India occur at home, largely due to the inability to afford hospital services.² This economic barrier significantly contributes to the high MMR in the country.

Structural factors

Inadequate transport facilities

Inadequate transport facilities for pregnant women particularly in remote areas, pose another significant challenge.¹⁵ Women living in rural regions often face difficulties in accessing healthcare facilities due to poor transport infrastructure. In many cases, women must travel long distances on foot to reach a hospital, increasing the risk of complications and maternal deaths.³  

Inadequate Infrastructure and quality of care in primary healthcare centers (PHC)

A barrier to providing maternal and newborn services in India is inadequate clinical infrastructure.¹⁵ Primary healthcare centers (PHCs) often provide substandard care due to a lack of qualified doctors and medical supplies ³, leading to unsanitary conditions and poor monitoring during labor and postpartum. Improving care quality and access to skilled assistance during childbirth, especially in low-income settings, is essential.²¹

Social factors 

Illiteracy

Social determinants, such as illiteracy and lack of awareness, also play a critical role in maternal mortality. Women with minimal or lack of formal education often struggle to express their healthcare requirements and comprehend medical advice. This lack of knowledge acts as a barrier to seeking medical care in healthcare centres.^3,19

Effect of the pandemic

The COVID-19 pandemic had grossly impacted the lives of people all over the world since December 2019. The pandemic led to an increase in the number of home births due to the fear of contracting the infection and because of financial constraints during the lockdown period.^5,18 This posed a threat to maternal and child life due to the absence of referral facilities and an infection-free environment.⁴ COVID-19 itself does not cause maternal mortality but is indirectly responsible for unsupervised pregnancies and the absence of routine antenatal visits thereby posing a threat to maternal health.⁵

Government Initiatives and Potential Solutions

Addressing the high maternal mortality rate in India requires a multifaceted approach that tackles both the direct and indirect causes of maternal deaths. Several government initiatives have been implemented to improve maternal healthcare (refer to Appendix Table 2), but challenges remain in ensuring their effectiveness.

Maternal Health in Other Low and Middle-Income Countries

Even in other low and middle countries like Bangladesh and Sri Lanka, the incidence and prevalence of PPH remain a major factor contributing to maternal death, followed by anemia and eclampsia.³⁶ 

Hemorrhage

In Bangladesh, hemorrhage accounts for 28.37% of maternal deaths, mainly from postpartum hemorrhage (PPH). A study done in Sri Lanka found PPH is responsible for 20% of maternal deaths. Low-income individuals are more at risk due to limited access to education, timely medical care, and quality healthcare, highlighting financial barriers to seeking medical assistance.³⁷

Anemia

In low and middle-income countries (LMICs), approximately 50% of pregnant women are anemic, affecting 32 million globally. Contributing factors include dietary iron deficiency, hemoglobinopathies, micronutrient deficiencies, and infections such as malaria, HIV, and hookworm. Anemia has been associated with increased antepartum and postpartum hemorrhage.³⁸ The Reproductive Health Management Information System (RHMIS) reports that 29.1% of pregnant women in Sri Lanka suffer from anemia, prompting maternal health concerns. To address this, interventions such as nutritional counselling, deworming, and double iron doses for those diagnosed with anemia have been implemented by the public health system.⁴² A study in Bangladesh found that 43.9% of female participants had anemia, with prevalence influenced by socio-demographic factors like education and financial status. Similar findings were reported in other LMICs such as Pakistan, India, and China, showing high anemia rates among women with little formal education and those from lower socio-economic backgrounds.⁴³

Hypertensive disorders

Preeclampsia and eclampsia are serious hypertensive disorders occurring during pregnancy and postpartum, with eclampsia being a major cause of maternal mortality, especially in low- and middle-income countries (LMICs) due to illiteracy, poor health awareness, poverty, and superstitions.⁴⁶ In Bangladesh, the maternal mortality ratio related to these conditions stagnated from 2010 to 2016. During this period, fatalities from preeclampsia and eclampsia were notably higher among underprivileged social groups, particularly those from rural and impoverished households. The stagnation indicates that while maternal healthcare in Bangladesh has reduced deaths among low-risk mothers, it struggles with critical and emergency obstetric situations.⁴⁰ In Sri Lanka, pregnancy-induced hypertension (PIH), toxemia and eclampsia, were the leading causes of maternal mortality until 1948. The introduction of comprehensive antenatal care significantly reduced maternal deaths by nearly 50%, thanks to improved clinical management, the use of antihypertensives, and magnesium sulphate, and the development of national guidelines.⁴¹

Social, economic, and structural barriers

In LMICs, the rural population face major barriers to emergency healthcare, particularly for obstetric complications, due to long distances and poor infrastructure. In Bangladesh, where healthcare investment is low, 75% of women give birth at home, and only 29% seek institutional care for obstetric issues as of 2010. One of the reasons for the increase in the number of home births is travel times to health centers which can range from 30 minutes to 3.5 hours, with transportation costs averaging 752 taka (CAD $10.74). Women's literacy also affects healthcare access, as educated women are more likely to seek modern services than illiterate women.^44,45  Similarly in Sri Lanka, it was noted that rural women are less likely to deliver in a healthcare center due to distance to the hospital, inadequate transportation, financial constraints, or lack of formal education.⁴⁵

Effect of Covid-19

During the lockdown in Bangladesh, the prevalence of institutional deliveries and antenatal care declined, increasing the risk of preventable maternal and child mortality.⁴⁸ A similar trend occurred in Sri Lanka, where missed antenatal appointments and reduced nutritional expenditure were reported due to the lockdown and insufficient financial aid.⁴⁷ Fear of infection, financial barriers, and inadequate safety equipment further hindered access to antenatal and prenatal care. However, targeted interventions are needed to restore maternal health services to pre-pandemic levels.⁴⁸ Delays in decision-making and healthcare delivery at the primary health centers in India, Bangladesh, Sri Lanka, and Nepal contribute to maternal deaths, highlighting the need for efficient decision-making and healthcare delivery to reduce MMR and enhance maternal health outcomes.⁴⁰

Rationale

The rationale for this research lies in the need to understand the multifaceted factors contributing to the high MMR in India. While previous studies have often focused on either socioeconomic factors or biological complications, this research aims to investigate both direct and indirect factors contributing to maternal mortality and explore the interrelationships between these factors. By examining these connections, the study seeks to uncover potential solutions that could help reduce MMR in India.

Research Question

Do indirect factors drive the direct factors and influence the MMR in India?

Objectives

• To identify the economic, social, and structural factors responsible for maternal death and its influence on MMR.
• To investigate the biological complications resulting from these indirect causes.
• To explore government initiatives and other possible solutions to improve maternal health outcomes and reduce MMR in India. 

Methods

This study employed a quantitative systematic review, involving the thorough examination and analysis of past primary and systematic review articles that address similar aspects of maternal mortality. A systematic review allows the researcher to objectively summarise a large amount of information from different articles, enabling a comprehensive assessment of the evidence related to specific research questions. This approach is characterized by meticulous planning and is known for producing reliable and accurate results. 

Eligibility Criteria

Inclusion criteria:

The review included primary research and systematic review articles published in English between January 2014 and April 2024, regardless of study design or setting. The studies selected explored both indirect and direct factors impacting the maternal mortality rate (MMR) across different regions of India. These studies covered diverse geographic areas, including northern, southern, eastern, and western India, with a focus on maternal health and prenatal care. The primary outcomes of interest were the MMR in India over the last decade and the government programs and initiatives aimed at reducing it.

Exclusion criteria:

Articles that were non-peer-reviewed articles published as editorials, commentaries, reports, and letters discussing the influence of social, economic, and structural factors on MMR were not incorporated in this review. Additionally, primary articles based on infant mortality, studies concerning countries other than India, and publications before 2014 were also excluded.

Search Strategy

A comprehensive literature search was conducted using PubMed and Google Scholar between May 1, 2024, and May 31, 2024. The review was restricted to studies published in English and conducted in India within the last 10 years from (2014 to 2024). (PubMed: https://pubmed.ncbi.nlm.nih.gov/, Google Scholar: https://scholar.google.ca/). Additionally, a manual search in the bibliographic references of the selected primary review articles was also conducted for additional relevant articles. The website of Care Health Insurance was also used to gain further insights into the direct and indirect factors influencing MMR in India. (Care health insurance: https://www.careinsurance.com/). Keywords and search terms like ‘maternal mortality’, ‘hemorrhage’, ‘anemia’, ‘hypertensive disorders’, ‘transportation’, ‘inadequate health facilities’, ‘financial constraints’ and ‘education’ were used. In PubMed, filters were applied to include only free full-text articles published within the last 10 years. Additional filters such as ‘human’ (species), ‘English’ (language), and ‘women’ (sex) were also utilized. The search strategy used in the study was based on the PICO (Population, Intervention, Comparison, Outcome) framework, as summarized in Appendix Figure 1.

Study Selection

The author manually screened the titles and abstracts of the retrieved articles based on the predefined inclusion and exclusion criteria. No automatic tools were utilized during the study selection process. This manual selection ensured that only the most relevant studies were included in the review.

Data Extraction

Data collection, screening, and extraction were performed manually in line with the review's specific objective and inclusion/exclusion criteria, without the use of software or automation tools. Studies published before 2014 were excluded, and only data pertinent to India were considered, even when the studies included information from other countries, such as Kenya or the United States.

Data Analysis

For this research, data from various articles were analyzed to identify correlations between indirect and direct factors contributing to MMR in India. This analysis involved extracting relevant data from multiple sources and drawing logical conclusions based on the causal relationships between dependent and independent factors driving towards a common outcome which is a reduction in MMR across India. The data analysis included the interpretation of various statistical and non-statistical trends, tables and reports presented by previous research articles in this domain.

Risk of Bias Assessment

Before including studies in the review, each was rigorously evaluated by the author for methodological quality, potential risk of bias, and the validity of their findings. The author referred to existing systematic review articles to determine the various domains of risk bias. The tool used for creating the risk of bias table for each included study was robvis (https://mcguinlu.shinyapps.io/robvis/), which facilitated a clear and systematic assessment of bias. The assessment involved four key domains, categorized into high, low, moderate, and unclear risk, depending on the bias involved:

1. Geographical Representation: This domain evaluated whether the study population was representative of the entire population of India. Studies focusing on specific states or regions received high scores, while those covering broader national data were given low scores.
2. Appropriateness of Study Subjects and Settings: This domain assessed whether the study’s settings and population were adequately described. Studies with detailed descriptions were assigned low scores, while those lacking clarity received unclear scores.
3. Appropriate statistical analysis: All included studies exhibited low bias in their statistical analysis, indicating a robust examination of trends, patterns, and relationships using quantitative data.
4. Sample size: Studies were classified based on the sufficiency of their sample sizes. High scores were given to studies with small sample sizes, low scores were given to those with adequate sample sizes, and unclear scores were assigned where sample sizes were not specified.

Each study was then categorized as having a high, low, or unclear overall risk of bias based on the assessment across these domains.⁵⁰ The author appraised each article before including it in the review.

Results 

Study Selection

The initial search yielded 60 articles from electronic databases. The duplicates(n=7) were identified and excluded from the study. After identifying and excluding duplicates (n=7), the remaining articles were screened based on their titles using specific search terms. Following this, the abstracts were reviewed, and only free full-text articles were considered for inclusion. Nine articles unavailable in full-text format were excluded, leaving 26 articles to be assessed for eligibility. After a thorough review using the PICO style approach, 8 articles that effectively addressed the research question were selected for the study. Figure 1 presents the PRISMA flowchart, which details the selection process and the reasons for excluding certain studies. 

Figure 1: Study selection process described through a PRISMA flowchart.

Study Characteristics

Among the 8 studies included in this research, 7 focused on specific states and regions in India, including Warangal [22], Udaipur [7], Haryana [24], West Bengal [10], northeast India [27], Jodhpur [5] and Gorakhpur [25]. One study provided data covering the entire country. [23]. The study design varied, comprising prospective studies [22,7,24,28,5], retrospective studies [10,25], cross-sectional studies [30], observational studies [7,5], or cohort studies [24]. In one study, the data was collected from a record book of past patients [23]. The primary participants in these studies were pregnant women and women of reproductive age. A detailed overview of the study characteristics is provided in Appendix Table 1.

Risk of bias assessment

1. In the first domain, which pertains to Geographical Representation, 7/8 studies received low scores.
2. In the second domain, concerning the Appropriateness of Study Subjects and Settings, 7/8 studies achieved high scores, with only one study receiving an unclear score.
3. The third domain, which evaluates Appropriate Statistical Analysis, saw all 8 studies scoring highly.
4. Lastly, in the domain of Appropriate Sample Size, 4/8 studies scored well, while 2 scored poorly, and 2 received unclear ratings.

The risk of bias of the included studies has been visually represented in Figure 2.

Figure 2: Risk of bias for all the included studies.⁵⁰

 The results of the risk of bias are illustrated in Table 1.

Table 1:  An overview of the potential risk of bias present in the studies. 

Postpartum Hemorrhage (PPH)

A prospective study conducted at a tertiary care center in Warangal, India, found that PPH is responsible for approximately a quarter of maternal deaths worldwide, with its incidence being particularly high in developing countries like India. The study, which included 8,027 deliveries, identified 171 cases of PPH. The highest risk was observed in women aged 26-30 years (37.5%), followed by those aged 21-25 years (27.5%), in the age group 31- 35 years (25%), 36-30 years (6.3%) and finally < 20 years of age (3.7%).²² Another study, conducted over six years from 2014 to 2019 in a tertiary care setup, showed a decline in the percentage of PPH from 3.35% to 2.38%. Figure 3 illustrates this trend over the six years.²³

Figure 3: Line graph depicting the percentage of PPH over 6 years.²³

Social and Economic Factors Influencing Anemia

Several studies from India highlighted that anemia during pregnancy significantly increases the risk of PPH, infections, cardiac failure, pre-eclampsia, and adverse fetal outcomes, including low birth weight and preterm delivery. A study conducted in Udaipur, Rajasthan, between February 2019 and July 2020, involved 70 consecutive multigravida pregnant women with moderate to severe anemia in their third trimester. The study found that 64.28% of the women affected by anemia belonged to lower socioeconomic status, 67.14% were illiterate, and only 12.85% were from the upper class.⁷ Table 2 summarizes the distribution of anemia based on socioeconomic status and education level.

Table 2: Percentage of women affected by anemia due to socioeconomic class and education level.⁷ 

Impact of Hypertensive Disorders on Maternal Mortality

Hypertensive disorders complicate 5%-10% of pregnancies and are a significant contributor to maternal mortality. A prospective, cross-sectional study in Northeast India from January 2016 to January 2019 reported that out of 5,460 deliveries, 402 cases (7.4%) involved hypertensive disorders in pregnancy (HDP). Severe preeclampsia was the most common, accounting for 33.6% of cases, followed by gestational hypertension and mild preeclampsia (both 27.6%). Eclampsia accounted for 11.2% of cases, with a maternal mortality rate of 2.9%.²⁷ Similarly, a 2021 study in North India reported that preeclampsia and eclampsia were the most prevalent hypertensive disorders, with preeclampsia being the most common.^24,27 Similarly, a 2021 study in North India reported that preeclampsia and eclampsia were the most prevalent hypertensive disorders, with preeclampsia being the most common. A retrospective study from West Bengal, conducted over five years (2008-2012), found that 111 out of 256 maternal deaths were due to eclampsia.¹⁰

Table 3 details the distribution of maternal deaths due to eclampsia according to social demographic characteristics.

Table 3: Distribution of maternal deaths due to eclampsia across five years (total n=111) according to the social demographic characteristics.¹⁰

Structural and Social Barriers to Prenatal Care

Social and structural barriers, including delays in obtaining transport, poor education, and inadequate infrastructure, significantly contribute to maternal mortality. A retrospective study conducted at BRD Medical College, Gorakhpur, between June 2017 and 2019, investigated the factors causing delays in receiving timely medical help. The study reported 107 maternal deaths out of 9,080 live births, with the most significant factor being a combination of Type 1 and Type 2 delays, accounting for 43.92% of cases. Table 4 provides a summary of the delays responsible for maternal mortality.²⁵

Table 4: Factors causing maternal mortality due to delay in receiving timely medical help. ²⁵

Effect of COVID-19 on Maternal Health

A prospective observational study conducted at the All India Institute of Medical Sciences, Jodhpur, from April to August 2020, assessed the impact of the COVID-19 pandemic on institutional deliveries. The study compared data from the pre-COVID-19 period (October 2019 to February 2020) with the COVID-19 period (April to August 2020), showing a 45.1% decrease in deliveries during the pandemic. The reduction in institutional deliveries was primarily due to the strict lockdown, which disrupted transportation and access to healthcare facilities.⁵ 

Figure 4: Number of deliveries in the pre-COVID-19 and COVID-19 times.⁵

Discussion

The primary objective of this systematic review was to investigate the interrelationship between the direct and indirect factors contributing to maternal mortality in India. This review focussed on key direct factors such as PPH, hypertensive disorders, and anemia as well as indirect factors like illiteracy, inadequate infrastructure, the effect of the COVID-19 pandemic, and poverty, all of which collectively present significant challenges in improving maternal health outcomes in India.

Postpartum Hemorrhage (PPH)

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality globally, especially in low-resource settings like India. Meh et al. (2021) noted the highest prevalence of maternal deaths from PPH in women aged 20– 29, particularly in poorer states.¹ Parlapally et al. (2022) and Madan et al. (2020) also reported that women belonging to the age group of 21- 29 years and 30-35 years face higher PPH risk.^22,23 Despite declining incidence due to improved healthcare, challenges remain, including delays in recognizing symptoms and accessing care.⁴⁹ To address this, the Indian government promotes misoprostol for home births, distributed by ASHAs, but issues like drug shortages and operational difficulties hinder its effectiveness.¹⁴

Anemia 

Anemia is a significant contributor to maternal mortality in India, particularly among women from lower socioeconomic backgrounds. Financial constraints and poverty exacerbate maternal health risks, with limited awareness of nutritional needs during pregnancy.⁷ Stevens et al. (2014) and Williams et al. (2020) observed that anemia prevalence remains high in India and other LMICs, increasing the risk of complications such as PPH and pre-eclampsia.^11,12 While, improving women’s economic condition, body mass index (BMI) and education levels can reduce anemia rates, targeted nutritional initiatives, iron supplements, and public health campaigns promoting IFA are essential. The RANI project, launched by the Indian government, encourages IFA consumption through social norm strategies.^11,13

Impact of Hypertensive Disorders on Maternal Mortality

Eclampsia is a major cause of hypertensive disorders during pregnancy, particularly affecting women from low socioeconomic backgrounds in rural areas. Das and Biswas (2015) found that a lack of awareness about eclampsia symptoms often leads to delayed medical help resulting in maternal deaths at home.^8,25 Early referral to intensive care units, improved education and good antenatal care can reduce its incidence and complications.¹⁰ To address the financial barriers, India’s Janani Suraksha Yojana (JSY) provides free maternal healthcare services. While JSY has reduced maternal and neonatal mortality, challenges like poor care quality, inadequate infrastructure, and corruption hinder its full potential.^19,33

Structural and Social Barriers to Receiving Prenatal Care

Women in India face considerable barriers to accessing timely healthcare, such as inadequate infrastructure, household responsibilities, and lack of education and awareness. Dalal et al. (2020) identified these challenges as key contributors to delays in seeking medical care, leading to adverse health outcomes. The primary causes of delays include difficulties in decision-making, unawareness of danger signs, and poor transportation. Addressing these issues requires improving women's education, transportation systems, and rural healthcare infrastructure.³

The Mobile for Mothers (MfM) app, launched by NEEDS and SIMAVI in 2011, has increased maternal health awareness through content in Hindi, integrating modern healthcare practices with local beliefs. However, the app lacks focus on empowering women and addressing systemic healthcare issues. A holistic approach that combines digital health initiatives with women's empowerment is essential.³⁵ The Mamta Vahan scheme aims to provide free ambulance services for pregnant women, but delays and transportation limitations have resulted in tragic outcomes, highlighting the need for a more reliable system.¹⁶

Effect of COVID-19 on Maternal Health

The COVID-19 pandemic posed unprecedented challenges to maternal health in India. Naqvi et al. (2022) compared pre-pandemic data (March 2019-February 2020) with the early pandemic period (March 2020 to February 2021), finding a modest increase in home births and a decrease in physician-attended deliveries. Although maternal mortality and stillbirths did not spike, access to healthcare was impacted. Goyal et al. (2021) also reported a decline in institutional deliveries during the lockdown, as many women, fearing contagion or lacking transport, chose home births or nearby facilities.

Additionally, the economic challenges worsened access to healthcare, with the lockdown reducing purchasing power.⁵ India responded by increasing hospital beds, setting up maternity spaces for COVID-19 patients, and distributing PPE.^5,26

Mental health issues, including stress, depression, and anxiety, also surged, especially for women facing increased household responsibilities and isolation.^30,33 Maternal anxiety is linked to negative pregnancy outcomes, highlighting the need for family support and quality antenatal care.^30,31,32 To address the challenges identified in this review, several actionable recommendations can be proposed (see Appendix Table 3).

Future Directions

• Future research should focus on exploring additional direct and indirect factors contributing to maternal mortality in India, such as traditional cultural practices, domestic violence, and environmental conditions.
• Studies should focus on cost-effective strategies to reduce maternal mortality in resource-limited settings, including longitudinal research on the potential complications faced by women and children facing barriers related to accessing medical care due to indirect factors.
• Research should also evaluate the impact of policy changes on maternal health, assess the effectiveness of the existing government initiatives, and identify gaps in policy implementation to improve programs aimed at reducing maternal mortality.

Strengths and Limitations

This systematic review offers a comprehensive examination of the direct and indirect factors responsible for maternal mortality, highlighting the complex interplay between biological complications and socioeconomic determinants. This review encompasses studies from diverse geographical regions across India. Additionally, the review attempts to correlate direct factors like PPH, anemia, and hypertensive disorders with indirect factors such as poverty, illiteracy, and inadequate infrastructure, offering insights into how these elements converge to impact maternal health. However, this review is not without its limitations. The study was constrained by the number of databases utilized and the restricted number of articles reviewed, potentially narrowing the scope of findings. Additionally, the reliance on data from secondary sources means that the accuracy and relevance of the findings are dependent on the quality of the original studies. Moreover, the data was sourced from studies conducted at various points in time, which might affect the consistency of the results.

Conclusion

This systematic review highlights the multifaceted nature of maternal mortality in India, revealing how direct biological factors, such as PPH, anemia, and hypertensive disorders, are intricately linked to indirect factors like socioeconomic conditions, educational attainment, infrastructure, and the impact of the COVID-19 pandemic. Tackling these challenges requires a comprehensive approach that includes enhancing healthcare infrastructure, advancing women’s education and economic status, and empowering them to make informed decisions about their health. The review also underscores the necessity for targeted governmental initiatives, including the Janani Suraksha Yojana (JSY), the Mamta Vahan scheme, Mobile for Mothers (MfM), and the RANI project, all of which have shown potential in improving maternal health outcomes. Continued efforts to refine and broaden these programs, particularly in reaching the most vulnerable populations, are essential for reducing maternal mortality rates in India. If India continues to improve these initiatives and address key social and structural determinants of health, it can achieve the Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030.¹

Acknowledgements

This research paper was completed within the framework of BeMo Academic Consulting’s Pre-Med Research Program. BeMo's contribution played a crucial role in enhancing the quality of this work and I extend my gratitude for their invaluable guidance and support.

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 Appendix

Appendix Figure 1: Search strategy by PICO method.

Appendix Table 1: Baseline characteristics of the included studies.

Appendix Table 2: Government initiatives to reduce MMR.

Appendix Table 3: Actionable recommendations to improve maternal health.