India has done something remarkable with regard to maternal survival, and the headline numbers indicate this. The national maternal mortality ratio fell from 130 per 100,000 live births in 2014–16 to 93 in 2019–21, and the most recent bulletin puts it lower still, at 88 for 2021–23. ¹ Facility birth has become the rule rather than the exception, reaching 88.6% of deliveries by 2019–21, with a skilled attendant present at a similar share. ² Cash incentives and free public delivery have pulled millions of women in, and on its present path the country should pass the Sustainable Development Goal threshold of 70 ahead of 2030. A few would have predicted this two decades ago.

The national figure hides, as it shows. Kerala sits at 20, the kind of number you would expect in a rich country, while Madhya Pradesh and Assam are still at 175 and 167 ( Figure 1). ¹ A woman’s chance of surviving childbirth depends heavily on which state she lives in. The same pattern holds over time. India’s national ratio has fallen steadily across successive Sample Registration System rounds, but the worst-performing states have not kept pace, and at 167 to 175 today Madhya Pradesh and Assam sit roughly where the country as a whole stood in 2011–13 ( Figure 2). ¹ On this measure they are close to a decade behind.

Who dies and why completes the picture? The remaining deaths fall disproportionately in women who are rural, poor, tribal, and less schooled and occur in the three places Thaddeus and Maine identified 30 years ago: in deciding to seek care, in reaching a facility, and in getting adequate treatment once there. ³ These delays rarely arrive on their own. They stack on one another and on poverty, distance, caste, and gender, so a single woman is exposed to several things at once. It is this compounding of disadvantage, rather than any one barrier, that makes death difficult to prevent.

These numbers bear this out: Of the roughly 1.3 million maternal deaths India recorded over the two decades to 2020, close to two-thirds occurred in its poorer states, and obstetric hemorrhage, the most treatable of the major causes, accounted for almost half, more so in those same states. ⁴ A study of nearly two million pregnant women across the nine high-burden states put the local maternal mortality ratio at 383, far above the national figure, and found that women without any health-financing scheme were more than two and a half times as likely to die. ⁵ Scheduled-caste and scheduled-tribe women carried added risk. The same analysis offered a hopeful corollary: much of the danger attached to poverty fell away once a woman had reliable access to care during pregnancy and childbirth. This barrier is not destiny. It is design.

The money runs through all of these. Even with free public delivery and cash transfers, out-of-pocket spending on institutional birth has increased in most settings, and it regularly tips poor households into borrowing and distress sales. The caesarean rate, now near a fifth of births, runs at roughly twice the level clinical need would warrant and add to the bill. ⁶ So the binding constraint has shifted. Getting women into a facility is no longer the main problem: what happens once they arrive and whether the poorest reaches care at all? Antenatal care shows the same fault line: only about three in five women completed the four recommended visits, and fewer than one in five reached the eight World Health Organization advises, with the shortfall concentrated among poor and uninsured women. ² India’s remaining maternal burden is therefore less a question of national capacity than of distribution, financial protection, acceptability, and the quality of care at the margins.

Where should India look for new ideas? The usual reflex is to benchmark against rich countries, but their budgets and staffing have remained out of reach for a decade or more. The better comparators were places that began poorer than India and still moved faster; above all on equity, India now struggles with. Approximately 260,000 women died of maternal causes worldwide in 2023, roughly one every two minutes, and the steepest falls have come from low- and middle-income countries that rebuilt how care reaches women rather than simply spending more. ⁷ Two of them, one in sub-Saharan Africa and one in Latin America, speak directly to India’s three delays.

They are ordered according to their priority. The first is foundational and the remainder reinforces it. 1.

Target the gap, not the average. Make the spread between states rather than the national mean; figure leadership answers. Set firm and audit milestones for the worst-affected states and aspirational districts, report progress against them publicly, and steer extra staff, supervision, and money to where the stacked disadvantages sit rather than spreading it evenly.

India has shown that it can shift its national maternal mortality rate. The work that remains is harder to do and harder to measure because it is about distribution: making the odds for a woman in Assam or in a tribal block of Madhya Pradesh look more like the odds for a woman in Kerala. Rwanda and Peru, both poorer than India when they began, suggest that this is within reach without waiting for a wealthy country’s budget, provided that the system is rebuilt around financial protection, a trusted community workforce, audited quality, and real respect for the women it is meant to serve.

These two precautions tempered the comparison. Rwanda and Peru are far smaller and more centrally governed than any large Indian state, and an instrument that worked in Kigali or the Peruvian sierra will not transfer unchanged to Bihar or the northeast, which lies in principles rather than templates. Cross-country figures rest on different data systems and baseline years; therefore, they describe direction and magnitude rather than a like-for-like ledger. What India needs next is not another national average but better disaggregated, district-level evidence on where deaths cluster and why, and implementation research that tests whether bundling financial protection, a strengthened frontline, and audited quality actually move outcomes in the highest-burden districts. What India needs most, in the end, is not new technology. However, this was a different target.

Ethical approval and consent were not required.