ImpactMojoMaternal Health 101www.impactmojo.in

ImpactMojo 101 Series · Free Forever

Maternal
Health
101

Why Mothers Die — and How They Survive: a Foundational Course for Development & Public-Health Practitioners in South Asia

Research-BackedSouth Asia Focus100 SlidesFree Access

ImpactMojoMaternal Health 101www.impactmojo.in

Agenda

What We Cover

Why Maternal Health Matters

Slides 3–10

Why Mothers Die

Slides 11–19

The Three Delays

Slides 20–28

The Continuum of Care

Slides 29–36

Antenatal Care

Slides 37–45

Skilled Birth & Institutional Delivery

Slides 46–54

Emergency Obstetric & Newborn Care

Slides 55–63

Postnatal & Newborn Care

Slides 64–72

Family Planning & Safe Abortion

Slides 73–81

Social Determinants & Equity

Slides 82–90

India's Programmes & Progress

Slides 91–99

ImpactMojoMaternal Health 101www.impactmojo.in

Section One

Why Maternal Health Matters

ImpactMojoMaternal Health 101www.impactmojo.in

The Stakes

A death that should almost never happen

A maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy — but not from accidental causes.

The tragedy is not that it happens, but that it almost always should not. The vast majority of maternal deaths are preventable with care that already exists.

Term	What it counts
Maternal death	Death while pregnant or within 42 days of the pregnancy ending, from a cause related to or aggravated by it
Late maternal death	The same, but 42 days to one year — increasingly counted, historically invisible
Pregnancy-related death	Any death in that window, including accidents — easier to measure, less specific

The 42-day cutoff is a measurement convention, not a clinical fact. A woman who dies of postpartum cardiomyopathy on day 50 died of her pregnancy and is excluded from the headline count.

The definition matters because it decides what a country is held to. Widening it raises the reported number without a single additional death — which is why comparisons across countries need the definition checked first.

ImpactMojoMaternal Health 101www.impactmojo.in

Definitions

Speaking the same language

Maternal Mortality Ratio (MMR)

The number of maternal deaths per 100,000 live births. The headline measure of how safe pregnancy and childbirth are in a population.

Maternal Mortality Rate

Maternal deaths per 100,000 women of reproductive age — reflects both the risk per pregnancy and how often women become pregnant. Distinct from the ratio.

Measure	Denominator	Answers
MMR (ratio)	Per 100,000 live births	How dangerous is a pregnancy here?
Maternal mortality rate	Per 100,000 women 15–49	How much maternal death does this population carry?
Lifetime risk	Per woman	Cumulative risk across a whole reproductive life

Two places can share an MMR and differ several-fold in lifetime risk, because lifetime risk multiplies the per-pregnancy danger by how many pregnancies a woman has. Falling fertility lowers lifetime risk even when care does not improve.

When a report says "maternal mortality rate" it usually means the ratio. Check the denominator before comparing two numbers — the confusion is common enough that it has changed policy conclusions.

ImpactMojoMaternal Health 101www.impactmojo.in

A Rights Issue

Maternal health is a human right

Safe motherhood is not charity. It flows from the rights to life, health, equality and non-discrimination — affirmed in the constitution and in international human-rights law.

More women die in pregnancy and childbirth than from almost any other cause — and they die because their lives are not valued enough to prevent it.

— a foundational claim of the safe-motherhood movement

Right	What it obliges the state to do
Life & health	Provide emergency obstetric care that is actually reachable
Non-discrimination	Close gaps by caste, poverty and district, not just raise the average
Information	Danger signs, entitlements and what a facility must provide free
Consent & dignity	No procedure without consent; no abuse or refusal of care

Framing maternal death as a rights violation changes who is accountable. A tragedy asks for sympathy; a violation asks which duty-bearer failed, and creates standing to demand redress.

Indian courts have used this framing directly — treating denial of maternal care in public facilities as a breach of the right to life under Article 21, with compensation ordered. The right is justiciable, not aspirational.

ImpactMojoMaternal Health 101www.impactmojo.in

The Global Target

SDG 3.1: the world's promise

< 70

global MMR target per 100,000 live births by 2030

SDG 3.1

2030

the deadline every country signed up to

SDG 3.1 also sets a national floor: no country with an MMR above 140 — twice the global average — by 2030. Equity, not just the average, is the goal.

SDG 3.1 component	The target
Global average MMR	Below 70 per 100,000 live births by 2030
National floor	No country above 140 — twice the global target
Sub-national	Not in the target, and where the real gaps sit

India's national MMR has crossed the 100 mark and is approaching the SDG-aligned threshold (SRS Special Bulletins). The national number is genuinely close to target; several states are not.

The 140 floor exists because a global average can be met while whole countries stay catastrophic. The same logic applies one level down: a national average can be met while whole states stay above 150, and nothing in SDG 3.1 catches that.

ImpactMojoMaternal Health 101www.impactmojo.in

Mostly Preventable

Most maternal deaths are preventable

The clinical causes of maternal death are well understood and the remedies are known, cheap and decades old: a trained attendant, a drug to stop bleeding, antibiotics, a timely caesarean, safe blood.

This is what makes maternal mortality a justice problem, not only a medical one. Women die not because we lack the knowledge, but because care does not reach them in time.

Complication	The remedy	Age of the remedy
Postpartum haemorrhage	Oxytocin at delivery; blood	In use since the 1950s
Eclampsia	Magnesium sulphate	Confirmed superior by the MAGPIE trial, 2002
Sepsis	Clean delivery; antibiotics	Semmelweis, 1847; antibiotics from the 1940s
Obstructed labour	Timely caesarean	Routine since the early 20th century

Nothing on this list is new, patented or expensive. Oxytocin and magnesium sulphate cost a few rupees a dose. What fails is the supply chain, the staffing roster and the road — not the science.

This is why maternal mortality tracks state capacity so closely. It is one of the few health indicators where the technical problem is solved and the remaining gap is almost purely one of delivery and equity.

ImpactMojoMaternal Health 101www.impactmojo.in

Where It Happens

A burden concentrated in the poorest places

Almost all maternal deaths occur in low- and lower-middle-income countries; sub-Saharan Africa and Southern Asia together carry the overwhelming majority. Within countries, the burden falls hardest on the poor and remote.

A woman's risk of dying in childbirth can vary many-fold between her district and a richer one in the same state. Maternal health is a map of inequality.

Level of comparison	Typical spread
Between world regions	Sub-Saharan Africa carries the highest regional MMR by a wide margin
Between Indian states	Kerala near 20; the highest-burden states above 150 (SRS 2019–21)
Between districts in one state	Often wider than the state-to-state gap
Between wealth quintiles	The poorest fifth lags on every stage of the continuum

The gap inside India is roughly as large as the gap between world regions. A woman in one Indian state faces something close to eight times the risk of a woman in another, under the same national law and the same set of schemes.

That gap is the argument for disaggregation as a habit rather than an add-on: a programme judged on the national MMR can be succeeding on paper while the districts carrying the burden do not move at all.

ImpactMojoMaternal Health 101www.impactmojo.in

This Course

How this course is built

The problem

Why mothers die — direct & indirect causes
The three delays that kill
The continuum of care that saves

The response

Antenatal, skilled birth, emergency & postnatal care
Family planning, safe abortion, equity
India's programmes and its progress

Throughout, the lens is South Asian and India-centric — the systems and schemes you will actually work within.

Section	The question it answers
Why mothers die	What is the clinical cause, direct and indirect?
The three delays	Where in the system did the time go?
The continuum of care	Which stage did she fall out of?
Programmes & equity	What is the state doing, and for whom is it not working?

The four questions are asked in that order deliberately. The clinical cause is what a death certificate records; the delay is what a death review finds; the continuum is where a programme intervenes.

If you work in MEL, programme design or advocacy rather than clinical care, the middle two sections are the ones you will use most — they are the layer where the system, not the body, decides the outcome.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Two

Why Mothers Die

ImpactMojoMaternal Health 101www.impactmojo.in

Two Families of Cause

Direct and indirect causes

Direct

Deaths from obstetric complications of pregnancy, labour and the postpartum — or from their treatment. Haemorrhage, sepsis, eclampsia, obstructed labour, unsafe abortion.

Indirect

Deaths from pre-existing or new conditions aggravated by pregnancy — anaemia, heart disease, diabetes, infections like TB or malaria.

Both matter. As direct deaths fall with better obstetric care, indirect causes — especially anaemia — make up a larger share of the remaining burden.

	Direct	Indirect
Arises from	The pregnancy itself or its management	A condition the pregnancy worsens
Examples	Haemorrhage, sepsis, eclampsia, obstructed labour	Anaemia, heart disease, TB, diabetes, hepatitis
Responds to	Obstetric care at the right moment	Care across the whole life course
Trend as systems improve	Falls first	Becomes the larger share of what remains

The shift from direct to indirect is a marker of progress, and it catches programmes out. A district that has fixed its labour rooms finds its remaining deaths are anaemic women and women with untreated heart disease — problems no labour room can solve.

In South Asia the direct/indirect line is blurred in practice: anaemia rarely appears as the certified cause, but it is what turns a survivable haemorrhage into a fatal one. Attribution understates it systematically.

ImpactMojoMaternal Health 101www.impactmojo.in

The Big Picture

What kills mothers: the leading causes

Distribution of direct maternal deaths by cause (illustrative pattern)

Illustrative; patterned on WHO global cause-of-death analyses

Direct cause	Approximate global share
Haemorrhage	About a quarter — the largest single cause
Hypertensive disorders	Roughly one in seven
Sepsis	About one in ten
Unsafe abortion	Close to one in twelve, and avoidable outright

Bleeding is the biggest killer worldwide, but shares vary widely by country: where abortion is legal and available that share nears zero, and where it is not it can lead.

Never plan a district programme from a global distribution — use your own death review data.

ImpactMojoMaternal Health 101www.impactmojo.in

Direct Cause #1

Haemorrhage: death in minutes

Obstetric haemorrhage — severe bleeding, most often after delivery (postpartum haemorrhage, PPH) — is the leading direct cause of maternal death. A woman can bleed to death in under two hours.

It is also among the most treatable: a uterotonic drug (oxytocin) given right after birth, prompt referral, and access to safe blood prevent most PPH deaths.

PPH response	Time available
Uterotonic within one minute of birth	Preventive — before bleeding starts
Recognise and call for help	Minutes
Uterine massage, controlled cord traction	Minutes
Reach blood transfusion	Under two hours, often less

PPH is the complication where distance kills most directly. A woman can bleed to death faster than an ambulance can cover 40 km of rural road, which is why prevention at the moment of birth — not referral — is the primary defence.

Oxytocin needs a cold chain; heat-stable carbetocin and misoprostol were developed for exactly the settings where the cold chain fails. Which uterotonic a facility stocks is a supply-chain decision with a mortality consequence.

ImpactMojoMaternal Health 101www.impactmojo.in

Direct Cause #2

Hypertensive disorders & eclampsia

Pre-eclampsia — high blood pressure with protein in the urine — can progress to eclampsia, where the mother convulses. Both threaten mother and baby.

BP + protein

the warning signs antenatal care screens for

MgSO₄

magnesium sulphate prevents & controls seizures — cheap, effective

Stage	Sign	Action
Pre-eclampsia	BP raised, protein in urine	Detected at ANC; monitor, treat, plan delivery
Severe pre-eclampsia	Headache, visual changes, upper abdominal pain	MgSO₄ and referral
Eclampsia	Convulsions	MgSO₄, stabilise, deliver

Magnesium sulphate more than halves the risk of eclampsia in women with pre-eclampsia (MAGPIE trial, 2002) and outperforms diazepam and phenytoin once seizures start. It costs very little and needs no refrigeration.

The failure mode is not the drug but the blood-pressure cuff and the urine dipstick. Pre-eclampsia is silent until it is severe, so a woman who never had her BP measured cannot be found in time.

ImpactMojoMaternal Health 101www.impactmojo.in

Direct Cause #3

Sepsis: infection after birth

Puerperal sepsis is a serious infection of the genital tract after childbirth or abortion, often from unhygienic delivery practices or prolonged labour. It can become fatal within days.

Clean hands, clean delivery surface, clean cord care and timely antibiotics — the 'six cleans' of safe delivery — prevent most cases.

The six cleans	Prevents
Clean hands	Introducing infection during examination and delivery
Clean delivery surface	Contamination at the moment of birth
Clean blade	Cord infection and neonatal tetanus
Clean cord tie and clean cord stump	The commonest route into a newborn
Clean perineum	Puerperal sepsis in the mother

Sepsis is slower than haemorrhage, and that is what makes it deceptive. A woman discharged well six hours after delivery can present septic on day three — by which time she is at home and no one is watching.

Prolonged labour, repeated vaginal examinations and unclean instruments are the main drivers. Two of the three are things a facility does, which is why facility sepsis rates are a quality indicator, not just a hygiene one.

ImpactMojoMaternal Health 101www.impactmojo.in

Direct Causes #4 & #5

Obstructed labour & unsafe abortion

Obstructed labour

The baby cannot pass through the birth canal. Without a timely caesarean it can cause rupture, death, or lifelong obstetric fistula.

Unsafe abortion

Termination by untrained people or in unsafe conditions. A wholly preventable cause — legal, safe abortion services eliminate it.

Both point to the same fix: a skilled attendant and access to emergency and safe services when they are needed.

Complication	If treated in time	If not
Obstructed labour	Caesarean; mother and baby survive	Uterine rupture, death, or obstetric fistula and lifelong incontinence
Unsafe abortion	Does not arise — safe services exist	Sepsis, haemorrhage, perforation, death

Obstetric fistula is the survivor’s injury. A woman who lives through days of obstructed labour may be left incontinent, and is then frequently abandoned — a social catastrophe produced entirely by a delayed caesarean.

Both causes are concentrated among the young, the poor and the remote — the women furthest from a theatre and least able to reach a registered provider. Neither is a medical mystery; both are access failures.

ImpactMojoMaternal Health 101www.impactmojo.in

Indirect Causes

Anaemia: the silent multiplier

Anaemia — too little haemoglobin to carry oxygen — rarely kills on its own, but it weakens a woman so that bleeding, infection or a difficult labour becomes lethal. It is the great indirect killer in South Asia.

~52%

of pregnant women aged 15–49 in India anaemic

NFHS-5, 2019–21

Iron + folic acid

supplementation & diet are the front-line response

Anaemia severity	Haemoglobin	Consequence in pregnancy
Mild	10.0–10.9 g/dL	Fatigue; reduced reserve for blood loss
Moderate	7.0–9.9 g/dL	Preterm birth, low birthweight, poor tolerance of haemorrhage
Severe	Below 7.0 g/dL	Heart failure; a routine blood loss becomes fatal

Anaemia converts survivable events into deaths. A woman with Hb of 6 has no reserve: the 500 ml blood loss that a healthy woman absorbs without incident can put her into shock.

This is why anaemia is the great indirect killer — it almost never appears on the death certificate, and it is present in the background of a large share of South Asian maternal deaths.

ImpactMojoMaternal Health 101www.impactmojo.in

When Death Strikes

The most dangerous hours

Most maternal deaths cluster around labour, delivery and the first 24 hours postpartum — the window when haemorrhage, eclampsia and obstructed labour turn fatal.

This is why a skilled attendant at birth and rapid access to emergency care matter more than almost anything else. The danger is concentrated, and so the response must be ready.

Window	What kills	What is needed
Labour and delivery	Obstructed labour, eclampsia	A skilled attendant; a theatre within reach
First 24 hours	Postpartum haemorrhage	Uterotonic at birth; observation; blood
First week	Sepsis, late haemorrhage	Postnatal contact, not early discharge
Up to 42 days	Sepsis, indirect causes	Home visits and a route back into care

The risk is concentrated into hours, and services are organised around days. That mismatch is the reason a woman discharged four hours after an uncomplicated delivery is sent home into her most dangerous window.

It also sets the priority order for a weak system: an attendant at birth and a working referral beat almost any other single investment, because they cover the hours where most of the deaths are.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Three

The Three Delays

ImpactMojoMaternal Health 101www.impactmojo.in

The Framework

Why women die: the three delays

The clinical cause is only the final step. Behind most maternal deaths lies a fatal delay. The 'three delays' model (Thaddeus & Maine, 1994) maps where the system fails.

The three delays

Delay 1: in deciding to seek care. Delay 2: in reaching a facility. Delay 3: in receiving adequate care once there. A death usually reflects more than one.

Delay	Located in	Who can act on it
1. Deciding to seek care	The household	ASHA, community, the woman herself
2. Reaching a facility	The road and the transport system	District administration, referral transport
3. Receiving adequate care	The facility	Health system managers, clinicians

Thaddeus and Maine published this in 1994 (Too far to walk: maternal mortality in context). It has outlasted three decades of clinical change because it is about time, and the clock is the one thing every maternal death has in common.

Its practical value is that each delay has a different owner. A programme that only trains clinicians is working on delay three and can achieve nothing if the women are dying at delay one.

ImpactMojoMaternal Health 101www.impactmojo.in

Visualised

The path from complication to outcome

Each delay is a place where the system — and we — can intervene to keep a mother alive.

ImpactMojoMaternal Health 101www.impactmojo.in

Delay One

Delay 1: deciding to seek care

The family does not recognise the danger, or hesitates — because of cost, distance, custom, or the low value placed on a woman's health.

Danger signs not known or dismissed as 'normal'
Decision rests with a husband or elder, not the woman
Fear of cost, or of the facility itself
Belief that birth is a private, home affair

Why the decision stalls	What shortens it
Danger signs read as normal discomfort	Danger-sign counselling at every ANC contact
The woman cannot decide alone	Counselling that includes husbands and mothers-in-law
Fear of the bill	JSSK entitlements, made known before labour
Distrust of how she will be treated	Respectful care — the strongest determinant of return

Delay one is not ignorance. It is usually a rational calculation under bad information: the cost is certain and immediate, the danger is uncertain, and someone else is making the decision.

Which is why an ASHA who has already accompanied a neighbour and knows the entitlements shifts this delay more than a poster does. The intervention is a trusted person, not a message.

ImpactMojoMaternal Health 101www.impactmojo.in

Delay Two

Delay 2: reaching care

The family decides to go — but cannot get there in time. Roads, distance, transport and terrain become matters of life and death.

No vehicle, or no money for one, at 2 a.m.
Long distance to the nearest functioning facility
Monsoon, hills or rivers cutting off villages
No referral transport linking village to hospital

Barrier	What actually fixes it
No vehicle at 2 a.m.	A dispatch system that answers at night — 102 / 108
No money for transport	Free referral transport under JSSK, both ways
Distance and terrain	Birth-waiting homes near the referral facility
Referred onward from the first facility	Correct routing at the start — not the nearest, the capable

The second referral is the one that kills. A woman taken to a facility that cannot manage her complication, then sent onward, has spent her margin on the wrong journey.

Ambulance coverage statistics count vehicles, not response times at night in the monsoon. When assessing delay two, ask what happened on the worst night of last year, not what the fleet size is.

ImpactMojoMaternal Health 101www.impactmojo.in

Delay Three

Delay 3: receiving adequate care

She reaches the facility — and still does not get what she needs. The third delay happens inside the system.

No doctor, no blood, no working theatre on duty
Stockouts of oxytocin, magnesium sulphate, antibiotics
Staff unable to manage the complication; further referral
Delays in payment, paperwork or decision-making

Inside the facility	The failure
Staffing	No one on duty who can manage the complication, on that shift
Drugs	Oxytocin or MgSO₄ out of stock, or out of cold chain
Blood	No functioning bank, or no matched unit
Theatre	No anaesthetist — the commonest reason a caesarean waits
Process	Admission paperwork, informal payment, decision by someone absent

Delay three is the one that rising institutional delivery makes more important, not less. Once nine in ten births are in facilities, the remaining deaths are increasingly of women who did reach care.

The anaesthetist is the classic single point of failure: a district hospital with an obstetrician, a theatre and no anaesthetist on night duty has a caesarean capability that exists only on paper.

ImpactMojoMaternal Health 101www.impactmojo.in

What It Teaches

Why the model changed everything

Before the three-delays model, maternal death was framed as a purely medical event. The model reframed it as a systems failure — spanning the household, the road and the hospital.

The insight: to save mothers you must fix all three delays at once. A perfect hospital is useless if she never reaches it; perfect transport is useless if it has nowhere to take her.

Framing	Question it asks	What it produces
Medical	What was the cause of death?	A cause on a certificate
Three delays	Where did the time go?	A list of system failures with owners

Fixing one delay can move deaths to another rather than prevent them. A cash incentive that succeeds at delay one delivers more women to labour rooms that are not ready — which is the story of the decade after JSY.

So the model is also a warning about sequencing: demand-side and supply-side investment have to move together, or the second delay simply becomes the third.

ImpactMojoMaternal Health 101www.impactmojo.in

Matching Solutions

Each delay has its own remedy

Delay	Root cause	What helps
1. Deciding	Awareness, cost, gender norms	ASHA outreach, danger-sign education, cash incentives
2. Reaching	Distance, transport	Referral ambulances (e.g. 102/108), birth-waiting homes
3. Receiving	Facility readiness	EmONC, staff, drugs, blood, free entitlements

India's flagship schemes map directly onto these three delays — a useful lens for any programme you design or assess.

Delay	India’s instrument	Its limit
1. Deciding	ASHA outreach; JSY cash incentive	Cash cannot buy quality once she arrives
2. Reaching	Free referral transport, 102 / 108; JSSK	Dispatch and night coverage vary widely
3. Receiving	EmONC, LaQshya, SUMAN, free entitlements	Depends on staffing that money alone cannot fix

Read the scheme map as a chronology and it tells the strategy. JSY (2005) attacks delay one, JSSK (2011) delays one and two, LaQshya and SUMAN attack delay three — the sequence a system follows once coverage stops being the binding constraint.

When you assess a district programme, ask which delay it is designed for and check whether that is the delay actually killing women there. The mismatch is common.

ImpactMojoMaternal Health 101www.impactmojo.in

Use It

A diagnostic you can apply tomorrow

When you review a maternal death — in a verbal autopsy, a case review, or a community meeting — walk it through the three delays. Where did the time go?

Most deaths reveal failures at more than one delay. Naming each one turns a tragedy into a list of fixable, system-level actions.

Death review question	Delay it interrogates
When did the family first notice something wrong?	Delay 1 — recognition
How long between noticing and leaving?	Delay 1 — decision
How long was the journey, and how many stops?	Delay 2
How long from arrival to first treatment?	Delay 3
What was missing when it was needed?	Delay 3 — readiness

Verbal autopsy and facility-based death review both use this spine. Timings recalled by families are approximate, but the sequence is usually reliable, and the sequence is what identifies the failure.

Maternal Death Surveillance and Response only works if the review is no-blame. A review that ends in a suspension produces no further reported deaths — and no further information.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Four

The Continuum of Care

ImpactMojoMaternal Health 101www.impactmojo.in

The Big Idea

Care is a chain, not a single event

Maternal and newborn health is not one moment — it is a continuum that runs from before pregnancy, through pregnancy, birth and the weeks after, into early childhood. A break anywhere puts mother and baby at risk.

Continuum of care

Linked, uninterrupted care across time (pre-pregnancy → pregnancy → birth → postnatal → childhood) and across place (home → community → facility).

Handover	Where women fall out
Pregnancy → birth	ANC attended, delivery at home unattended
Birth → postnatal	Discharged within hours; no contact in the fatal window
Postnatal → family planning	No counselling; next pregnancy too soon
Mother → newborn	The baby is never separately examined

Every one of these is a handover, not a service. Coverage statistics measure services; women die at the joins, which nothing routinely counts.

A useful district question: of the women who attended four ANC visits, how many had a postnatal contact within 48 hours? The drop between two coverage figures is the continuum failing, and it is usually large.

ImpactMojoMaternal Health 101www.impactmojo.in

The Stages

The four core stages

ANTENATAL: care through pregnancy

→

SKILLED BIRTH: a trained attendant at delivery

→

POSTNATAL: mother & newborn in the first 6 weeks

→

NEWBORN: care of the baby from the first minute

Each stage protects against specific risks — and each handover between stages is where women fall out of the system.

Stage	The risk it manages	If skipped
Antenatal	Anaemia, hypertension, malpresentation	Silent risks arrive as emergencies
Skilled birth	Haemorrhage, eclampsia, obstruction	The most dangerous hours are unattended
Postnatal	PPH, sepsis, newborn danger signs	Deaths occur at home, uncounted
Newborn	Asphyxia, hypothermia, infection	Most newborn deaths are in the first week

The stages are not substitutes. Excellent antenatal care does not compensate for an unattended birth, because they manage different risks in different windows.

This is the argument against single-intervention programmes. Each stage removes one class of death; the residual is whatever the missing stages would have caught.

ImpactMojoMaternal Health 101www.impactmojo.in

Two Dimensions

Across time and across place

Across time

Pre-pregnancy → antenatal → birth → postnatal → childhood. No stage skipped.

Across place

Home and community (ASHA, ANM) linked to facilities (PHC, CHC, district hospital) by referral.

Strong systems connect both dimensions — the home visit and the operating theatre are part of one chain.

Dimension	Breaks when
Across time	A stage is skipped — ANC without a skilled birth, birth without postnatal contact
Across place	The referral link fails — no transport, no slot, no record travelling with her

The two dimensions fail differently and need different fixes. A time gap is closed by outreach and follow-up; a place gap is closed by transport, communication and a receiving facility that knows she is coming.

The Mother and Child Protection Card is the cheap instrument that links both: a record the woman holds, so her history reaches whichever provider she meets next. It only works if providers actually write in it.

ImpactMojoMaternal Health 101www.impactmojo.in

The Weakest Links

Where the chain usually breaks

Women attend antenatal care but deliver at home unattended
They deliver in a facility but leave within hours, missing postnatal care
Referral between levels fails — no transport, no slot, no follow-up
The newborn is never separately checked

Coverage of any single stage is not enough. The question is whether each woman moves through all of them.

Coverage figure	What it does not tell you
4+ ANC visits	Whether BP and haemoglobin were actually measured
Institutional delivery	Whether the facility could manage a complication
Postnatal contact	Whether it happened inside the first 48 hours
Any single stage	Whether the same women received all of them

The last row is the important one. Four stages at 80% coverage each can mean 80% of women got everything, or it can mean a large group got nothing — and the aggregate figures look identical.

Longitudinal tracking by name, which India’s RCH and HMIS systems are designed to do, is what distinguishes the two. Where it works, it exposes a continuum-completion rate far below any individual coverage number.

ImpactMojoMaternal Health 101www.impactmojo.in

Who Delivers It

The frontline team

Cadre	Role	Based at
ASHA	Mobiliser, accompanies women, follow-up	Village
ANM	Antenatal checks, immunisation, deliveries	Sub-centre / HWC
Staff nurse / SBA	Skilled birth attendance	PHC / CHC
Medical officer	Complications, caesarean (where trained)	CHC / hospital
Specialist (Ob-Gyn)	Comprehensive emergency care	District hospital

The ASHA is the hinge of the whole continuum in India — the link between the household and the health system.

Cadre	Employment	Paid how
ASHA	Volunteer, not salaried staff	Task-based incentives per activity completed
ANM	Government staff	Salary
Staff nurse / SBA	Facility staff	Salary
Medical officer, specialist	Facility staff	Salary

The ASHA carries the continuum and is the only one not on a salary. Incentive payments are per completed task and are frequently delayed, which shapes which tasks get done and which quietly do not.

Any programme that adds a duty for ASHAs is adding unpaid or under-paid work to the busiest link in the chain. That is a design constraint, not a footnote — and a recurring cause of programmes that work in pilots and not at scale.

ImpactMojoMaternal Health 101www.impactmojo.in

Levels of Care

A referral system, tier by tier

SUB-CENTRE / HWC: antenatal, normal birth

→

PHC: basic emergency obstetric care

→

CHC / FRU: comprehensive care, caesarean, blood

→

DISTRICT HOSPITAL: full specialist & newborn care

Each tier handles what it can and refers up what it cannot. A functioning referral chain — with transport and communication — is what makes the continuum real.

Tier	Should handle	Refers up when
Sub-centre / HWC	ANC, normal birth, postnatal	Any danger sign appears
PHC	Basic EmONC — the seven signal functions	Caesarean or transfusion needed
CHC / FRU	Comprehensive EmONC: surgery and blood	ICU or specialist newborn care needed
District hospital	Full specialist and newborn care	Rarely

A First Referral Unit is a definition, not a signboard. The label requires round-the-clock caesarean, blood and newborn care; a facility designated FRU without an anaesthetist is not one, whatever the register says.

The UN benchmark is at least five EmONC facilities per 500,000 population, of which at least one comprehensive. Mapping your district against that — and against travel time, not straight-line distance — is the readiness test.

ImpactMojoMaternal Health 101www.impactmojo.in

The Payoff

Why the continuum saves lives

Antenatal care detects risk early; skilled birth manages the most dangerous hours; postnatal care catches haemorrhage and infection; newborn care protects the baby. Together they close the gaps no single intervention can.

The rest of this course follows the continuum — one stage at a time — before turning to family planning, equity and India's programmes.

Stage	Deaths it removes
Antenatal care	Eclampsia and anaemia-driven deaths, caught early
Skilled birth	Haemorrhage, obstruction — the labour-window deaths
Postnatal care	Late PPH and sepsis, in the window after discharge
Newborn care	Asphyxia, hypothermia, infection in the first week

Each stage removes a different class of death, so the returns are additive rather than overlapping. That is what makes the continuum worth more than the sum of its coverage statistics.

It also means the residual mortality in any district tells you which stage is weakest. Deaths clustering after discharge point at postnatal care; deaths in labour point at readiness and referral.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Five

Antenatal Care

ImpactMojoMaternal Health 101www.impactmojo.in

What & Why

Antenatal care: the first line of defence

Antenatal care (ANC)

The care a woman receives during pregnancy — check-ups, screening, advice, supplements and immunisation — to keep her and her baby healthy and to detect problems early.

Good ANC turns a silent risk into a managed one: it finds the anaemia, the rising blood pressure, the malpresentation — before they become emergencies.

ANC finds	Before it becomes
Raised BP and protein in urine	Eclampsia in labour
Low haemoglobin	A survivable blood loss turning fatal
Malpresentation, previous caesarean	Obstructed labour or rupture
Syphilis, HIV, hepatitis B	Transmission to the newborn
Gestational diabetes	Macrosomia and obstructed labour

Antenatal care converts an unknown risk into a managed one. Almost nothing on this list produces symptoms the woman would report; each is found only because someone tested for it.

Which is why a visit that records weight and hands over tablets is not antenatal care. The BP cuff, the haemoglobin test and the urine dipstick are what the visit is for.

ImpactMojoMaternal Health 101www.impactmojo.in

The Shift

From 4 contacts to 8: WHO's 2016 model

In 2016 WHO moved from a minimum of 4 antenatal visits to a recommended 8 contacts — more touchpoints, better outcomes, and a more positive pregnancy experience.

4 → 8

minimum visits raised to recommended contacts

WHO ANC model, 2016

1st trimester

the first contact should be early — before 12 weeks

	Old model (4 visits)	WHO 2016 (8 contacts)
First contact	Often second trimester	Before 12 weeks
Spacing	4 visits, mostly late	Contacts across all three trimesters
Framing	Risk screening	Screening plus a positive pregnancy experience
Wording	"Visit"	"Contact" — includes community-based care

The change from four to eight was driven by evidence that more contacts reduce perinatal deaths, and by the finding that risk screening alone misses most women who go on to develop complications.

The word change matters operationally: a "contact" can be delivered by a community health worker, which is what makes eight achievable in settings where eight facility visits are not.

ImpactMojoMaternal Health 101www.impactmojo.in

Coverage in India

How many women get full ANC?

Mothers with at least 4 antenatal visits, India (%)

NFHS rounds (NFHS-3, -4, -5); values rounded

Real improvement — but a large share of women still fall short of four visits, let alone eight. Early, complete ANC remains an unfinished agenda.

Indicator (NFHS-5, 2019–21)	India
At least four ANC visits	About 58% of mothers
First trimester ANC registration	Around seven in ten
Full ANC (4 visits, IFA, TT)	A much smaller minority

The gap between institutional delivery and full ANC is the story here. India got women into facilities far faster than it got them properly cared for in pregnancy.

"Full ANC" is the honest measure and the one rarely quoted, since it needs every component rather than a count of visits. Ask for it.

ImpactMojoMaternal Health 101www.impactmojo.in

The Danger Signs

What every pregnant woman should know

Vaginal bleeding
Severe headache, blurred vision (signs of pre-eclampsia)
High fever
Swelling of face and hands; convulsions
Reduced or absent fetal movement; leaking fluid

Teaching danger signs directly attacks Delay 1: a family that recognises the warning acts sooner.

Danger sign	Points to
Vaginal bleeding	Antepartum or postpartum haemorrhage
Severe headache, blurred vision, upper abdominal pain	Severe pre-eclampsia
Convulsions	Eclampsia — immediate MgSO₄ and referral
High fever, foul discharge	Sepsis
Reduced fetal movement, leaking fluid	Fetal distress, premature rupture

Counsel the decision-maker, not only the woman. In households where a husband or mother-in-law decides, teaching danger signs to the woman alone leaves the decision unchanged.

Pair the signs with a plan: which facility, whose phone, whose vehicle, what money. A recognised danger sign with no rehearsed next step still produces delay one.

ImpactMojoMaternal Health 101www.impactmojo.in

Anaemia & Nutrition

Fighting anaemia in pregnancy

Because anaemia underlies so many maternal deaths, ANC screens haemoglobin and counsels on a diet richer in iron, alongside supplementation.

Hb test

every pregnant woman should be screened for anaemia

Diet + IFA

iron-rich food plus supplements is the core response

Anaemia in India (NFHS-5)	Share
Pregnant women 15–49	About 52%
All women 15–49	About 57%
Children 6–59 months	About 67%

Anaemia rose between NFHS-4 and NFHS-5 in most states, against a decade of supplementation programmes. Whatever the cause — measurement method, diet, or programme reach — the trend is the wrong way.

Iron deficiency is the largest contributor but not the only one. Where hookworm, malaria or haemoglobinopathies such as sickle-cell and thalassaemia are common, iron alone will not close the gap.

ImpactMojoMaternal Health 101www.impactmojo.in

IFA

Iron and folic acid: the cheapest protection

Iron and folic acid (IFA) supplements raise haemoglobin and prevent neural-tube defects. The standard advice is daily IFA through pregnancy and into the postpartum period.

Cheap and effective — but only if women actually take the tablets. Counselling, supply and follow-up matter as much as the prescription itself.

Why IFA fails in practice	What helps
Nausea and constipation	Counselling on timing; taking it with food
Stopped after feeling better	Explaining it treats a silent condition
Stockouts at the sub-centre	Supply monitoring, not just prescription counts
Tablets counted as distributed, never taken	Consumption tracked, not distribution

Distribution figures are the wrong indicator and the one most often reported. Tablets handed over and tablets swallowed diverge widely, and only the second changes haemoglobin.

India’s Anemia Mukt Bharat strategy addresses this with testing, deworming and fortified staples alongside supplementation — an admission that IFA alone had not worked.

ImpactMojoMaternal Health 101www.impactmojo.in

TT / Td

Tetanus protection: a quiet success

Tetanus toxoid (now Td) vaccination of pregnant women protects against maternal and neonatal tetanus — once a major killer of newborns through infected cord-cutting.

Sustained TT coverage, alongside clean delivery, helped India eliminate maternal and neonatal tetanus as a public-health problem — proof that simple measures, at scale, save lives.

	Before TT at scale	After
Neonatal tetanus	A major cause of newborn death	Eliminated as a public-health problem in India, validated 2015
Route of infection	Unclean cord-cutting at home births	Clean delivery plus maternal immunity

Elimination here means below one case per 1,000 live births per district — not zero. It is a threshold that has to be held, and it slips where immunisation coverage falls.

Neonatal tetanus is the clearest proof in the chapter that a cheap intervention delivered consistently beats a sophisticated one delivered patchily. Two doses of a vaccine costing pennies closed a major killer.

ImpactMojoMaternal Health 101www.impactmojo.in

A Full ANC Visit

What a good check-up actually does

Weigh, measure blood pressure, test haemoglobin and urine
Check fetal growth, position and heartbeat
Give IFA, calcium and TT/Td; treat infections
Counsel on diet, danger signs and birth planning
Identify high-risk pregnancies and plan referral

A visit that only records weight is not ANC. Quality — not just the tick-box of attendance — is what protects the mother.

Component	Skipped when
Blood pressure	No working cuff, or a queue too long for it
Haemoglobin	No test strips; result not acted on
Urine protein	Dipsticks out of stock
Fetal growth and position	No trained provider that session
Birth planning and danger signs	No time — the first thing dropped

Every component drops out for a supply or staffing reason, not a clinical one. That makes ANC quality an operational problem, measurable by stock registers rather than by attendance.

PMSMA exists precisely for this: a fixed day each month with a specialist and a guaranteed package, so that quality is not left to whichever session a woman happens to attend.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Six

Skilled Birth & Institutional Delivery

ImpactMojoMaternal Health 101www.impactmojo.in

The Decisive Factor

A skilled attendant changes everything

Skilled birth attendant (SBA)

An accredited health professional — doctor, nurse or midwife — trained to manage normal birth and to recognise, manage or refer complications.

Because the deadliest complications strike during labour and the hours after, who attends the birth is the single most decisive factor in whether a mother lives.

Attendant	Can manage	Can refer with stabilisation
Skilled birth attendant	Normal birth; initial management of PPH, eclampsia	Yes — uterotonic, MgSO₄, first-line care
Traditional birth attendant	Normal birth, sometimes well	No clinical stabilisation
No attendant	Nothing	No

The evidence shifted policy here. Training traditional birth attendants was the strategy of the 1980s and did not reduce maternal mortality; the deaths need drugs, surgery and blood that no amount of training supplies.

That does not make TBAs irrelevant. Where they are trusted, their role shifts to recognition, accompaniment and clean practice — working with the system rather than substituting for it.

ImpactMojoMaternal Health 101www.impactmojo.in

Why Institutions

Why institutional delivery matters

A facility birth brings the woman to where the drugs, equipment, blood and skills are — so that when haemorrhage or eclampsia strikes, the response is minutes away, not hours.

A home birth with no trained help and no transport stacks all three delays at once. Institutional delivery is, above all, a strategy against delay.

Setting	Delay 1	Delay 2	Delay 3
Home, unattended	Full	Full — begins after the emergency	Full
Home, skilled attendant	Reduced	Still full	Partial
Facility birth	Already resolved	Already resolved	The only one left

Institutional delivery is best understood as pre-paying the first two delays. The woman is already where the care is when the emergency starts, which converts a two-hour problem into a two-minute one.

It also concentrates the entire risk on delay three. That is a good trade only if the facility is ready — which is why coverage gains and quality investment have to move together.

ImpactMojoMaternal Health 101www.impactmojo.in

The Trend

India's institutional-delivery surge

Institutional births in India (%)

NFHS rounds (NFHS-3, -4, -5); values rounded

One of India's great public-health shifts: from under half to roughly nine in ten births in a facility within fifteen years.

Institutional delivery, India	Share of births
NFHS-3 (2005–06)	About 39%
NFHS-4 (2015–16)	About 79%
NFHS-5 (2019–21)	About 89%

A shift of fifty percentage points in fifteen years is among the fastest changes in health-seeking behaviour recorded anywhere. JSY, the ASHA cadre and free entitlements together did that.

The gains are uneven: home births stay concentrated among the poorest quintile, Adivasi communities and the remotest blocks — the groups carrying the highest mortality.

ImpactMojoMaternal Health 101www.impactmojo.in

The Lever

JSY: paying women to deliver safely

Janani Suraksha Yojana (JSY), launched in 2005 under the National Rural Health Mission, is a conditional cash transfer: it pays eligible women a cash incentive to give birth in a health facility.

2005

JSY launched under NRHM

MoHFW

Cash on delivery

incentive paid for institutional birth, with the ASHA as link

JSY design element	Rationale
Cash to the mother	Covers transport, wages lost, incidental costs
Conditional on facility birth	Buys the behaviour that removes delays 1 and 2
ASHA incentive for accompaniment	Gives someone an interest in the woman arriving
Higher amounts in low-performing states	Targets where the gap is largest

JSY is a conditional cash transfer aimed at a single behaviour, and evaluations generally credit it with a substantial share of the rise in institutional delivery.

The recurring criticisms are worth knowing: payment delays that undercut the incentive, exclusion of women without documents, and no mechanism at all for what happens once she is inside.

ImpactMojoMaternal Health 101www.impactmojo.in

How JSY Works

Demand-side financing, in practice

JSY tackles the cost barrier behind Delays 1 and 2 — the money for transport, the wage lost, the fear of facility charges — by putting cash in the mother's hands for choosing a facility birth.

It is widely credited with driving the rise in institutional delivery. But cash gets her through the door; it cannot guarantee quality once she is inside — that is the next challenge.

What JSY can buy	What it cannot
The journey and the decision	An anaesthetist on night duty
A woman’s arrival at a facility	Oxytocin in stock when she bleeds
Higher coverage statistics	Respectful treatment once she is there

Demand-side financing has a ceiling set by supply. Once the women arrive, additional cash buys nothing further; the binding constraint moves to staffing, drugs and theatre capacity.

This is the general lesson for conditional cash transfers, not a criticism specific to JSY: they are effective at the behaviour they pay for and silent on everything downstream of it.

ImpactMojoMaternal Health 101www.impactmojo.in

Removing Cost

JSSK: free entitlements at delivery

Janani Shishu Suraksha Karyakram (JSSK), 2011, goes further: it entitles every pregnant woman to free delivery — including caesarean — in public facilities, with no out-of-pocket charge.

Free delivery, drugs, diagnostics and diet
Free blood and free referral transport
Same free entitlements for sick newborns

JSSK entitlement	The charge it removes
Free delivery, including caesarean	The largest single bill
Free drugs and consumables	Prescriptions sent to outside chemists
Free diagnostics and blood	Tests and units billed privately
Free transport, both ways and between facilities	The cost of getting there and home
Free diet during the stay	Food bought by the family

The entitlement is only as strong as the woman’s knowledge of it. Informal payments and outside prescriptions persist mainly where women do not know what is meant to be free.

Displaying entitlements in the labour room, in the local language, is one of the cheapest accountability measures available — and one of the first things to check on a facility visit.

ImpactMojoMaternal Health 101www.impactmojo.in

JSY vs JSSK

Two schemes, two barriers

	JSY (2005)	JSSK (2011)
Mechanism	Cash incentive to the woman	Free services, no charges
Barrier addressed	Decision & cost of coming	Cost incurred at facility
Type	Demand-side (conditional cash)	Supply-side entitlement
Together	Get her to come	Make sure it costs her nothing

JSY pulls women in; JSSK removes the bill once they arrive. The two are designed to work hand in hand.

ImpactMojoMaternal Health 101www.impactmojo.in

The Caveat

Coming is not the same as being cared for

A facility birth only saves a life if the facility is ready — staffed, stocked, and able to manage an emergency. A crowded labour room without drugs or a skilled provider is a false promise.

This is why India's focus has shifted from getting women in to quality of care — the agenda behind LaQshya and SUMAN, which we reach later.

Coverage indicator	The quality question it hides
89% institutional delivery	Was a skilled provider present at that birth?
Facility has a labour room	Is it staffed on every shift?
Designated FRU	Is there an anaesthetist at night?
Blood bank exists	Was a matched unit available within the hour?

India has largely won the coverage argument and inherited the quality one. When nine in ten births are in facilities, further mortality decline depends almost entirely on what happens inside them.

This is the transition that LaQshya and SUMAN were designed for, and it is harder than the first: coverage responds to cash and outreach, quality responds to staffing, supervision and culture.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Seven

Emergency Obstetric & Newborn Care

ImpactMojoMaternal Health 101www.impactmojo.in

The Last Line

When prevention is not enough

Some complications cannot be predicted or prevented — they simply happen. Emergency Obstetric and Newborn Care (EmONC) is the set of life-saving services that treat them when they do.

Most women who develop a complication have no known risk factor beforehand. That is why every birth needs access to emergency care — not just the 'high-risk' ones.

Assumption	Why it fails
High-risk women can be identified antenatally	Most complications arise in women with no risk factor
Risk screening lets us target scarce resources	It misdirects them — and reassures the wrong women
Only some births need emergency access	Every birth needs it, because the risk is unpredictable

This is the single most important idea in the section. The failure of risk screening as a targeting strategy is why the standard shifted to universal access to emergency care.

A woman told at ANC that she is "low risk" and reassured accordingly has been given false information. She may bleed as readily as anyone, and the reassurance can itself produce delay one.

ImpactMojoMaternal Health 101www.impactmojo.in

Two Levels

Basic vs comprehensive EmONC

Basic EmONC (BEmONC)

Delivered at PHC level without surgery: the seven 'signal functions' that stabilise most emergencies.

Comprehensive (CEmONC)

BEmONC plus caesarean section and safe blood transfusion — needs a hospital / FRU with theatre and blood bank.

A district needs enough of both, geographically spread, so that no woman is more than a short ride from the care she might suddenly need.

	BEmONC	CEmONC
Signal functions	Seven	Nine — adds caesarean and transfusion
Typical level	PHC	CHC / FRU / district hospital
Needs	Drugs, a trained provider	Theatre, anaesthetist, blood bank
UN benchmark per 500,000	At least five facilities	At least one of those five

Geography matters as much as count. Five EmONC facilities clustered in one town meet the numeric benchmark and leave half the district beyond reach; the benchmark assumes they are spread.

Assess a district by travel time in the worst conditions of the year, not by straight-line distance. A river in spate converts a 30-minute journey into an overnight one.

ImpactMojoMaternal Health 101www.impactmojo.in

Signal Functions

The seven basic signal functions

Give parenteral antibiotics (sepsis)
Give parenteral uterotonics (haemorrhage)
Give parenteral anticonvulsants — magnesium sulphate (eclampsia)
Manually remove the placenta
Remove retained products (post-abortion / post-delivery)
Perform assisted vaginal delivery
Perform basic newborn resuscitation

CEmONC adds two more: caesarean section and blood transfusion. These nine functions define a facility's real capability.

Signal function	Treats
Parenteral antibiotics	Sepsis
Parenteral uterotonics	Haemorrhage
Parenteral anticonvulsants (MgSO₄)	Eclampsia
Manual removal of placenta; removal of retained products	Haemorrhage from retained tissue
Assisted vaginal delivery; newborn resuscitation	Obstructed second stage; asphyxia

Signal functions are assessed by what a facility performed in the last three months, not by what it is equipped or authorised to do. A function never used is treated as absent, which is the right standard.

That definition catches the common failure: a PHC with MgSO₄ on the shelf and no provider confident enough to give it. The drug is in stock and the function is not available.

ImpactMojoMaternal Health 101www.impactmojo.in

Referral

The chain that makes EmONC work

EmONC is only as good as the referral system that moves a woman from where she is to where the care is — fast, with the right information arriving ahead of her.

Recognise the complication and decide to refer early
Pre-referral stabilisation (e.g. first dose of MgSO₄)
Functioning transport (ambulance 102 / 108)
Communication so the receiving facility is ready

Referral step	Failure that kills
Recognise and decide	Waiting to see if it settles
Stabilise before moving	Sending an eclamptic woman without the first MgSO₄ dose
Transport	No vehicle at night; no fuel; no driver
Communicate ahead	Arriving unannounced to an unprepared theatre
Records travel with her	History reconstructed from scratch on arrival

Pre-referral stabilisation is the step most often skipped and the one that buys the most time. The loading dose of magnesium sulphate can be given anywhere and protects her through the journey.

A referral without a phone call is a gamble on the receiving facility being ready. Ten minutes of warning is often the difference between a theatre prepared and a theatre being found.

ImpactMojoMaternal Health 101www.impactmojo.in

The Tool

The partograph: watching labour in time

Partograph

A simple chart used during labour to track the baby's descent, cervical dilation, the mother's vitals and the fetal heartbeat against time — with 'alert' and 'action' lines that signal when to intervene.

By making slow or obstructed labour visible early, the partograph turns a creeping emergency into a timely decision to act or refer.

Partograph line	Means	Action
Progress left of the alert line	Labour progressing normally	Continue observation
Crosses the alert line	Slower than expected	Reassess; prepare to refer
Crosses the action line	Intervention is overdue	Augment, refer or deliver operatively

The partograph works by making a slow process visible while there is still time. Obstructed labour has no dramatic moment; it is hours of nothing happening, which is easy to miss in a busy labour room.

WHO’s Labour Care Guide (2020) has since replaced the classic partograph, adjusting the alert thresholds — the underlying idea, plotting labour against time, is unchanged.

ImpactMojoMaternal Health 101www.impactmojo.in

Reading It

Why the partograph saves lives

When labour crosses the alert line, the team is warned; if it crosses the action line, intervention — augmentation, referral or caesarean — is overdue. It is a clock and a conscience in one page.

Low-cost, low-tech, high-impact: the partograph needs no electricity and catches obstructed labour before it ruptures the uterus or kills the baby.

ImpactMojoMaternal Health 101www.impactmojo.in

Newborn Side

The first minute: newborn resuscitation

Many newborns who do not breathe at birth can be revived with simple bag-and-mask resuscitation in the first minute — the 'golden minute'. No baby should die for want of this basic skill.

Skilling every birth attendant in newborn resuscitation links maternal and newborn survival: the same hands, the same moment, two lives.

First minute after birth	Action
Baby breathing or crying	Dry, keep warm, skin-to-skin, delay cord clamping
Not breathing	Dry, stimulate, clear airway if needed
Still not breathing	Bag-and-mask ventilation — within the first minute

Birth asphyxia is a leading cause of newborn death and needs no electricity to treat. A bag and mask costs very little; the constraint is a trained pair of hands present at every birth, on every shift.

Skills decay fast without practice. Programmes such as Helping Babies Breathe rely on regular low-dose refresher drills for this reason — a one-off training does not hold.

ImpactMojoMaternal Health 101www.impactmojo.in

System Readiness

What 'ready' really means

People: a skilled provider on duty, every shift
Drugs: oxytocin, magnesium sulphate, antibiotics in stock
Blood: a functioning supply for haemorrhage
Theatre: a working space for caesarean
Transport: referral that actually moves

A single missing link — a stockout, an absent doctor, a broken ambulance — can convert a survivable emergency into a death. Readiness is a whole-system property.

Element	Single point of failure
People	One skilled provider on the roster, on leave
Drugs	Oxytocin out of cold chain in summer
Blood	Bank exists; no matched unit tonight
Theatre	No anaesthetist — the commonest blocker
Transport	Ambulance out of fuel, or driver unreachable

Readiness is a conjunction, not a sum. Four elements present and one missing gives you zero capability, which is why facility scorecards averaging across components mislead.

Score readiness as a chain: the facility is as ready as its weakest element on its worst shift. That is the standard the woman actually meets.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Eight

Postnatal & Newborn Care

ImpactMojoMaternal Health 101www.impactmojo.in

The Forgotten Window

After birth: the neglected period

Care often stops at delivery — yet a large share of maternal and most newborn deaths occur after birth. The postnatal period is the most dangerous and the most neglected part of the continuum.

Women discharged within hours of delivery, with no follow-up, are sent home into the very window when haemorrhage and infection strike.

Why postnatal care is weakest	Consequence
Discharge within hours of delivery	She is at home through the highest-risk window
Bed pressure in busy labour rooms	Early discharge is an operational necessity
No incentive attached to postnatal contact	What is not paid for is not prioritised
Deaths at home go uncounted	The failure is invisible in facility data

The last row explains the first three. A death at home two days after discharge does not appear in the facility’s records, so the system that produced it receives no signal.

WHO recommends the first postnatal contact within 24 hours for every birth, facility or home. Measured honestly, this is among India’s weakest continuum indicators.

ImpactMojoMaternal Health 101www.impactmojo.in

The Timeline

The critical first 48 hours and 6 weeks

FIRST 24 HOURS: highest risk of PPH — do not discharge early

→

FIRST 48 HOURS: watch bleeding, BP, infection, breastfeeding

→

FIRST WEEK: home visits for mother & newborn

→

FIRST 6 WEEKS: complete recovery & family-planning counselling

WHO recommends at least the first postnatal contact within 24 hours, with further contacts over the following weeks — for facility and home births alike.

HBNC visit schedule (ASHA)	Days after birth
Institutional birth	3, 7, 14, 21, 28, 42
Home birth	1, 3, 7, 14, 21, 28, 42
Low birthweight or preterm	Additional visits, closer follow-up

Note what the institutional schedule omits: days one and two. The facility is meant to cover them, and does so only if the woman is still there — which after an early discharge she is not.

That gap between discharge and the day-three visit is where postpartum haemorrhage and early sepsis fall. Closing it means either holding women 48 hours or visiting sooner, and neither is free.

ImpactMojoMaternal Health 101www.impactmojo.in

The Main Threat

Postpartum haemorrhage after birth

Postpartum haemorrhage (PPH) — excessive bleeding after delivery — remains the top cause of postnatal maternal death. It can begin suddenly and kill within an hour or two.

Active management of the third stage of labour — a uterotonic at delivery, controlled cord traction, uterine massage — prevents most PPH. Vigilance in the first hours catches the rest.

AMTSL step	Timing
Uterotonic — oxytocin	Within one minute of birth
Controlled cord traction	With a contraction, after signs of separation
Uterine massage / tone assessment	Immediately and repeatedly after delivery
Observation	Continuous through the first hours

Active management of the third stage prevents most postpartum haemorrhage and takes about a minute. It is the highest-return single action in the whole course.

Blood loss is routinely underestimated by eye. Calibrated drapes exist because visual estimation misses the point at which a woman has crossed into danger.

ImpactMojoMaternal Health 101www.impactmojo.in

Home Outreach

Bringing care to the doorstep: HBNC

India's Home-Based Newborn Care (HBNC) programme has ASHAs visit mother and newborn at home on a fixed schedule in the first six weeks — checking, counselling, and referring danger signs.

These visits catch the deaths that the facility, by discharging early, would otherwise miss — and reach the women least likely to return on their own.

What the ASHA visit does	Catches
Checks the mother’s bleeding, fever, mood	Late PPH, sepsis, postpartum depression
Weighs and examines the newborn	Low birthweight, hypothermia, cord infection
Watches a feed	Feeding failure — the earliest sign of a sick baby
Refers on danger signs	The deaths facility data never sees

HBNC reaches the women least likely to come back on their own — the poorest, the furthest, and those who had a difficult experience at the facility.

The visits are incentive-paid and reported by the ASHA, so recorded coverage runs ahead of visits actually made. Verify by asking mothers, not by reading the register.

ImpactMojoMaternal Health 101www.impactmojo.in

Newborn Danger Signs

Warning signs in the baby

Not feeding well or unable to suckle
Fast, difficult, or very slow breathing
Fever or, dangerously, low body temperature
Lethargy, reduced movement, or convulsions
Yellowness, or redness/discharge at the cord

Most newborn deaths happen in the first week. Teaching families to recognise these signs — and to act — is core to postnatal care.

Newborn danger sign	Suggests
Not feeding, unable to suckle	Sepsis — the earliest and most reliable sign
Fast or difficult breathing	Pneumonia, respiratory distress
Fever, or low body temperature	Sepsis — hypothermia is the more dangerous of the two
Lethargy, convulsions, reduced movement	Serious infection or asphyxial injury
Redness or discharge at the cord	Omphalitis, a route to sepsis

Low temperature alarms families less than fever and is the worse sign. A cold, quiet newborn is often described as "sleeping well", which is why the counselling has to be explicit about it.

Most newborn deaths occur in the first week, and India’s neonatal mortality now makes up a large majority of its infant deaths. The remaining child-survival gains are concentrated here.

ImpactMojoMaternal Health 101www.impactmojo.in

Warmth & Skin-to-Skin

Kangaroo Mother Care

Kangaroo Mother Care (KMC) — continuous skin-to-skin contact, exclusive breastfeeding, and early discharge with support — dramatically improves survival of small and preterm babies.

Low-cost and powerful: the mother's body provides the warmth, the feeding and the bonding an incubator cannot. It works even where technology is scarce.

KMC provides	Instead of
Continuous skin-to-skin warmth	An incubator that needs power and maintenance
Exclusive breastfeeding, frequent feeds	Formula and separation
Constant monitoring by the mother	Intermittent monitoring by staff
Early discharge with follow-up	A prolonged, expensive admission

WHO now recommends immediate KMC for small and preterm babies, starting at birth rather than after stabilisation — a change from the older guidance, based on trials showing lower mortality when it begins straight away.

The barriers are institutional, not clinical: wards designed to separate mother and baby, and no place for a mother to sit continuously for days. Facilities that adopt KMC have to change their layout.

ImpactMojoMaternal Health 101www.impactmojo.in

Breastfeeding

The first hour, then six months

First hour

early initiation of breastfeeding within an hour of birth

6 months

exclusive breastfeeding — nothing but breast milk

Early and exclusive breastfeeding protects the newborn against infection and undernutrition — one of the most cost-effective child-survival interventions known.

Practice (NFHS-5)	India
Breastfeeding started within one hour	About 42% of births
Exclusively breastfed, under six months	About 64% of infants

Early initiation is the weaker of the two and the more fixable. It is decided in the first hour by whoever is present at the birth, which makes it a labour-room practice rather than a household behaviour.

Caesarean delivery, separation of mother and baby, and prelacteal feeds are the usual reasons the first hour is missed — all facility decisions, all changeable without any new resource.

ImpactMojoMaternal Health 101www.impactmojo.in

Mother & Baby Together

Postnatal care is a package

Mother: check bleeding, BP, infection, mood, breastfeeding
Newborn: weight, warmth, feeding, danger signs, immunisation
Counsel: nutrition, hygiene, and birth spacing
Refer: any danger sign in either, without delay

Mother and baby are one clinical unit in this window. Care that treats them together — at home and at the facility — closes the deadliest gap in the continuum.

Postnatal contact covers	Because
Mother: bleeding, BP, infection, mood	PPH, sepsis and eclampsia can still occur after discharge
Newborn: weight, warmth, feeding, danger signs	Most newborn deaths are in the first week
Counselling: nutrition, hygiene, birth spacing	The postpartum window is when family planning is most usable
Referral for either, immediately	Both deteriorate faster than adults do

Postpartum depression belongs on this list and is almost never screened for. It is common, treatable, and affects feeding and infant care directly — yet sits outside most postnatal protocols.

Treating mother and baby as one clinical unit is also an operational instruction: one visit, one record, one referral decision — not two vertical programmes meeting at the doorstep.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Nine

Family Planning & Safe Abortion

ImpactMojoMaternal Health 101www.impactmojo.in

The Link

Family planning is maternal survival

Every pregnancy carries risk. Letting women choose whether, when and how often to become pregnant directly reduces the number of high-risk pregnancies — and so reduces maternal death.

Family planning is one of the most cost-effective ways to save mothers' lives: fewer unintended pregnancies, fewer unsafe abortions, fewer dangerous births.

Mechanism	How it lowers maternal death
Fewer unintended pregnancies	Fewer exposures to the risk of pregnancy at all
Fewer unsafe abortions	Removes an entire direct cause
Better spacing	Avoids the depletion of closely spaced births
Avoiding highest-risk ages and parities	Removes the most dangerous pregnancies first

Contraception prevents maternal deaths without touching a single labour room. It is the only intervention in this course that reduces the denominator rather than improving the outcome.

Which is why family planning belongs in a maternal-health course rather than beside it. Modelling consistently shows meeting unmet need would avert a large share of remaining maternal deaths.

ImpactMojoMaternal Health 101www.impactmojo.in

Birth Spacing

Why timing and spacing matter

Too young: adolescent bodies face higher risk of obstructed labour, eclampsia and death
Too close: pregnancies spaced under two years deplete the mother and raise risk
Too many: high parity compounds the cumulative danger
Too old: risk rises again at the upper end of reproductive age

Avoiding the 'too young, too close, too many, too old' pregnancies is a direct maternal-health intervention.

Pattern	Added risk
Too young — under 18	Immature pelvis: obstructed labour, fistula, eclampsia
Too close — under 24 months apart	Maternal depletion, anaemia, preterm birth
Too many — high parity	Cumulative risk; uterine atony and haemorrhage
Too old — over 35	Hypertension, diabetes, chromosomal risk

All four are avoidable by contraception, and none by obstetric care. The clinical system can manage the consequences; only family planning prevents the exposure.

WHO recommends at least 24 months between a live birth and the next conception. Postpartum contraception matters because fertility returns before most couples expect it to.

ImpactMojoMaternal Health 101www.impactmojo.in

Unmet Need

Women who want to space but cannot

Unmet need for family planning

The share of women who want to delay or avoid pregnancy but are not using any method of contraception — a gap between desire and access.

Closing unmet need — through supply, choice and counselling — prevents unintended pregnancies and the unsafe abortions and risky births that follow them.

Reason for unmet need	What closes it
Method not available at the sub-centre	Supply chain, not counselling
Side effects experienced and unexplained	Counselling and follow-up, not a new method
Opposition from husband or family	Male engagement; discreet methods
Believed not to be at risk while breastfeeding	Accurate postpartum counselling

Unmet need is measured as a gap in intention, so it is not an argument for pushing methods. These are women who have already said they want to delay or stop; the failure is on the supply side.

India’s recorded unmet need has fallen to roughly one in ten women (NFHS-5), but discontinuation remains high — women start a method and stop it, which coverage figures do not capture.

ImpactMojoMaternal Health 101www.impactmojo.in

The Basket

A range of methods, freely chosen

Type	Examples	Note
Spacing	Condoms, pills, injectables, IUCD	Reversible; user's choice
Long-acting	IUCD, implants	Effective for years, reversible
Permanent	Female & male sterilisation	For those who want no more children
Emergency	Emergency contraceptive pill	After unprotected sex

The principle is informed choice, not targets. India's expanded basket (injectables, the Antara programme) widens options — quality counselling makes them real.

Method type	Typical duration	Consideration
Condoms, pills	Per act / daily	High discontinuation; user-dependent
Injectables (Antara)	Three months	Discreet; return of fertility is delayed
IUCD, including postpartum insertion	Up to ten years	Reversible; needs a trained inserter and follow-up
Sterilisation	Permanent	Requires genuine informed consent

India’s method mix is heavily weighted towards female sterilisation — a skew that reflects programme history and provider incentives more than what women, asked freely, choose.

A basket is only a basket if every method is actually in stock at the facility a woman can reach. Choice on a poster and choice at the sub-centre are different things.

ImpactMojoMaternal Health 101www.impactmojo.in

Rights, Not Targets

From population control to choice

Historically, family-planning programmes chased demographic targets, sometimes coercively. The modern, rights-based approach centres the woman's voluntary, informed decision.

Coercion — quotas, incentives that distort choice, camp sterilisations without consent — is both a rights violation and bad public health. Voluntary, quality services work better.

Target-driven era	Rights-based approach
Numerical method targets for workers	No targets; quality of counselling assessed
Sterilisation camps, volume incentives	Fixed-day services with full consent procedures
Success measured by acceptors	Success measured by need met and choice honoured
Coercion documented in several states	Consent, confidentiality, and the right to refuse

India abolished method-specific targets in 1996 after decades of coercive practice, including the mass sterilisations of the Emergency. The shift is real and the pressure recurs through incentive structures.

The Supreme Court’s 2016 ruling in Devika Biswas ordered the closure of sterilisation camps and set standards for consent and care — a reminder that this is settled law, not an aspiration.

ImpactMojoMaternal Health 101www.impactmojo.in

Safe Abortion

Unsafe abortion is a preventable death

Where safe, legal abortion is unavailable, women resort to unsafe methods — a wholly preventable cause of maternal death and injury. Access to safe abortion is a pillar of maternal survival.

The remedy is straightforward: legal services, trained providers, and the medicines and procedures that make abortion safe.

Where abortion is	Result
Legal, available, and safe	Unsafe abortion effectively disappears as a cause of death
Legal but not accessible	Unsafe abortion persists at scale
Restricted	Unsafe abortion becomes a leading cause of maternal death

Restricting abortion does not reduce abortion; it changes who performs it and under what conditions. This is one of the most consistently replicated findings in reproductive health.

Medical abortion with mifepristone and misoprostol has changed the safety picture substantially, including where formal services are thin — but it needs correct information and a route to care if it fails.

ImpactMojoMaternal Health 101www.impactmojo.in

The Law

India's MTP Act framework

The Medical Termination of Pregnancy (MTP) Act permits abortion under defined conditions by registered providers. The 2021 amendment expanded grounds and raised the gestational limit in specified circumstances.

Permitted on health, fetal, contraceptive-failure and other grounds
Must be performed by a registered medical practitioner
2021 amendment widened access and confidentiality protections

MTP Act provision	Position after the 2021 amendment
Up to 20 weeks	One registered medical practitioner’s opinion
20–24 weeks	Two practitioners’ opinion, for specified categories of women
Beyond 24 weeks	Only for substantial fetal abnormality, via a State Medical Board
Confidentiality	Explicit protection; disclosure is an offence
Contraceptive failure	Ground extended to any woman, not only married women

The Act is framed as protection for the provider, not as a right of the woman. It sets the conditions under which a doctor may lawfully perform an abortion, which is why access still depends on a provider’s willingness.

Abortion is also restricted in a second way: the PCPNDT Act bans sex determination. That is a distinct law with a distinct purpose, and conflating the two has been shown to deter lawful abortion care.

ImpactMojoMaternal Health 101www.impactmojo.in

Law vs Access

Legal does not yet mean reachable

A permissive law is necessary but not sufficient. Women still face stigma, provider shortages, lack of awareness, and refusal — so unsafe abortion persists despite legality.

Bridging the gap between the law on paper and services on the ground — trained providers, supplies, non-judgemental care — is the unfinished task.

Barrier after legalisation	What it takes
Too few trained, willing providers	Training and certification at district level
Providers wrongly fear PCPNDT liability	Clear guidance separating the two laws
Stigma; judgement at the facility	Non-judgemental care as a supervised standard
Women unaware it is legal	Public information, which almost nowhere exists

A large share of abortions in India still take place outside the formal system, five decades after legalisation. The law changed in 1971; access has not caught up.

Comprehensive abortion care includes post-abortion contraception. A woman who leaves without it is likely to return in the same situation, which is a failure of the service rather than of the woman.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Ten

Social Determinants & Equity

ImpactMojoMaternal Health 101www.impactmojo.in

The Deeper Causes

Beyond the clinic: why some women die

Clinical causes are the how; social determinants are the why. Poverty, gender, caste, education and geography decide who reaches care in time — and who does not.

Two women with the same complication can face very different odds, set long before labour begins, by where and to whom they were born.

Determinant	Acts through
Poverty	Cost of transport, wages lost, informal payments
Gender norms	Who decides, who may travel, whose health counts
Caste	Treatment at the facility; where facilities are placed
Education	Recognition of danger signs; confidence to demand care
Geography	Distance, terrain, season, road

Every one of these acts on delay one or delay two — before any clinician is involved. That is why maternal mortality tracks social position so closely even where facilities are formally free.

It also sets the limit of health-sector action. A health system can compensate for these determinants; it cannot remove them, and programmes that assume otherwise over-promise.

ImpactMojoMaternal Health 101www.impactmojo.in

Early Marriage

Child marriage & adolescent pregnancy

Girls married and pregnant as adolescents face far higher risk: their bodies are not ready, they have less power to seek care, and they are more likely to suffer obstructed labour and eclampsia.

Delaying marriage and first pregnancy — through education, agency and enforcement of the legal age — is one of the most powerful upstream maternal-health interventions.

Adolescent pregnancy raises	Because
Obstructed labour and fistula	The pelvis is not fully grown
Pre-eclampsia and eclampsia	Higher incidence in first pregnancies and in young mothers
Preterm birth and low birthweight	Maternal undernutrition and immaturity
Delay in seeking care	Least power in the household of anyone involved

The legal age of marriage for women in India is 18 (Prohibition of Child Marriage Act, 2006), and child marriage has fallen substantially — while remaining common in several states and among the poorest.

Keeping girls in secondary school is the intervention with the strongest evidence behind it, and it sits entirely outside the health system. Maternal health policy that ignores education is working with one hand.

ImpactMojoMaternal Health 101www.impactmojo.in

Anaemia & Nutrition

Lifelong undernutrition, compounded

A girl undernourished and anaemic through childhood enters pregnancy already depleted. Maternal anaemia is not just a clinical fact — it is the biological signature of a lifetime of inequality.

~52%

of pregnant women in India anaemic

NFHS-5, 2019–21

Life course

nutrition before pregnancy matters as much as during it

Life stage	What is lost
Girl child	Less food, later care than a brother in many households
Adolescence	Growth spurt plus menstrual loss, rarely supplemented
First pregnancy	Enters already depleted; supplementation starts too late
Between births	No recovery interval if spacing is short

Anaemia in pregnancy is the accumulated record of a life. Supplementation that begins at antenatal registration is treating the last few months of a twenty-year deficit.

This is the argument for anaemia programmes in schools and for adolescent girls — the point at which the deficit can still be corrected before a first pregnancy.

ImpactMojoMaternal Health 101www.impactmojo.in

The Gaps

Caste, poverty and region

Caste: Dalit and Adivasi women face worse access and outcomes
Poverty: the poorest quintile lags on ANC, skilled birth and survival
Region: MMR varies several-fold across Indian states
Rural & remote: distance and weak facilities raise every delay

National averages hide these gaps. Equity means asking not just 'how many?' but 'which women are still dying, and where?'

Cut the data by	Typical finding
Wealth quintile	The poorest fifth lags at every stage of the continuum
Caste and tribe	Adivasi women furthest from facilities; worse treatment on arrival
State	Kerala near 20; the highest-burden states above 150 (SRS 2019–21)
District within a state	Often a wider spread than between states
Rural / remote	Distance and weak facilities compound all three delays

The district is the unit where the gap is actionable. State averages are too coarse to direct resources and national ones tell you almost nothing about where women are dying.

India’s Aspirational Districts programme is built on exactly this logic — targeting the districts furthest behind rather than raising an average that is already respectable.

ImpactMojoMaternal Health 101www.impactmojo.in

See the Gap

Why disaggregation matters

Skilled birth attendance by wealth group (illustrative pattern)

Illustrative; patterned on NFHS-style wealth gradients

A good national average can still hide a poorest group left far behind. Disaggregation is how equity becomes visible — and actionable.

ImpactMojoMaternal Health 101www.impactmojo.in

Gender & Power

Whose body, whose decision?

Maternal health sits inside gender relations. When a woman cannot decide to seek care, control household money, or move without permission, her survival depends on others' choices.

Empowering women — education, income, mobility, voice — is not adjacent to maternal health. It is maternal health, working through Delay 1.

Constraint on the woman	Delay it produces
Cannot decide to seek care alone	Delay 1 — the decision waits for someone else
No control over household money	Delay 1 and 2 — cannot pay for transport
Cannot travel unaccompanied	Delay 2 — departure waits for an escort
Her health is not a household priority	All three — the underlying valuation

Women’s autonomy is not context for maternal health; it is a mechanism inside it, operating through delay one with the same directness as an ambulance operates on delay two.

This is why education, income and mobility show up in maternal-mortality regressions even after controlling for access to services. They change who is able to act, and how fast.

ImpactMojoMaternal Health 101www.impactmojo.in

Dignity in Birth

Respectful maternity care

Respectful maternity care (RMC)

Care that preserves a woman's dignity, privacy, consent and choice during pregnancy and childbirth — free from abuse, neglect or discrimination.

How a woman is treated is not a soft extra. Disrespect drives women away from facilities — reintroducing Delay 1 even where services exist.

RMC standard	Its violation
Dignity and privacy	Examination in view of others; no screens
Consent	Episiotomy or fundal pressure without asking
Freedom from abuse	Slapping, shouting, humiliation during labour
Non-discrimination	Worse treatment by caste, poverty or language
Companionship in labour	Family excluded by routine, not by need

A labour companion of the woman’s choice is a WHO recommendation with measurable clinical benefit — shorter labour, less intervention, better experience — and it is refused in most Indian labour rooms as a matter of routine.

Respectful care is measurable: exit interviews, consent documentation, companion presence. Where it is not measured, it is left to the culture of whoever is on duty.

ImpactMojoMaternal Health 101www.impactmojo.in

The Shadow Side

Obstetric violence

Obstetric violence — verbal abuse, non-consented procedures, neglect, discrimination by caste or poverty, demands for informal payment — is a real and documented barrier in many facilities.

A woman mistreated once may never return — and may warn others away. Respectful care is therefore not only ethical; it is essential to keeping the gains in institutional delivery.

Consequence of mistreatment	Shows up as
She does not return	A home birth next time, counted as a coverage failure
She warns others	A whole hamlet’s facility use falls
She arrives late	Delay 1 — caused by the facility itself
She delivers privately at any cost	Catastrophic health expenditure

Obstetric violence converts delay three into delay one for the next woman. That is the loop that makes it a mortality issue rather than only an ethical one.

Its immediate drivers are usually structural: overcrowded labour rooms, exhausted staff, no supervision and no consequence. Naming individuals without changing those conditions moves the behaviour rather than ending it.

ImpactMojoMaternal Health 101www.impactmojo.in

Section Eleven

India's Programmes & Progress

ImpactMojoMaternal Health 101www.impactmojo.in

The Architecture

The National Health Mission

India's maternal-health effort runs through the National Health Mission (NHM) — the umbrella under which JSY, JSSK, the ASHA cadre and quality programmes sit and connect.

Think of NHM as the system; the schemes that follow are its instruments — each targeting a specific delay or stage of the continuum.

NHM component	Contribution to maternal health
ASHA cadre	The link between household and system
Untied funds to facilities	Local purchase when the supply chain fails
Rogi Kalyan Samitis	Facility-level management and grievance route
Free entitlements (JSSK)	Removes cost at the point of care
Quality programmes (LaQshya, SUMAN)	Standards inside the labour room

NHM matters because it made the schemes fundable and staffable at state level. Before it, similar schemes existed on paper without the flexible finance or the frontline cadre to run them.

It also created the data systems — HMIS and name-based tracking — that make continuum completion measurable at all. What can be counted is a policy choice made here.

ImpactMojoMaternal Health 101www.impactmojo.in

The Scheme Map

How the programmes fit together

Programme	What it does	Targets
JSY (2005)	Cash incentive for facility birth	Delays 1 & 2
JSSK (2011)	Free delivery, drugs, transport, blood	Delay 2 & cost
PMSMA	Fixed-day free quality antenatal check-ups	ANC stage
LaQshya	Labour-room & maternity-OT quality	Delay 3 / quality
SUMAN	Assured, free, dignified maternal & newborn care	Whole continuum

Read down the column: the schemes evolved from getting women in toward guaranteeing quality and dignity once they arrive.

Scheme	Year	The gap it was created to close
JSY	2005	Women were not coming to facilities
JSSK	2011	Coming still cost them money
PMSMA	2016	Antenatal care was attended but not delivered
LaQshya	2017	Labour rooms were full and not ready
SUMAN	2019	Care was free but not assured or respectful

Read the years and the strategy is legible: each scheme answers the failure the previous one exposed. Demand first, then cost, then antenatal quality, then labour-room quality, then dignity.

The pattern is worth carrying into any programme design. Solving one constraint reveals the next, and a scheme that succeeds completely has, by succeeding, moved the problem somewhere else.

ImpactMojoMaternal Health 101www.impactmojo.in

The Frontline

ASHAs: the million-strong link

The Accredited Social Health Activist (ASHA) — a local woman trained as a community health worker — is the hinge of India's maternal-health system: mobilising, accompanying, following up, and earning incentives for each link she completes.

Nearly a million ASHAs connect households to the system. Much of India's progress on institutional delivery and ANC runs through them.

ASHA does	Paid
Registers the pregnancy, follows up ANC	Per activity
Accompanies the woman to the facility	Per institutional delivery
Makes the HBNC visits	Per completed schedule
Counsels on family planning, distributes commodities	Per activity
Everything not on the incentive list	Not paid

The incentive list is the job description in practice. Anything outside it competes with paid work, which is why unincentivised tasks — postnatal counselling, follow-up of a refused referral — are the first to lapse.

ASHAs are almost all women, drawn from the communities they serve, and were recognised with the WHO Director-General’s Global Health Leaders Award in 2022. They remain classified as volunteers.

ImpactMojoMaternal Health 101www.impactmojo.in

Quality Push

From access to assured quality

LaQshya

Labour Room Quality Improvement — raising the standard of care in labour rooms and maternity operating theatres.

SUMAN

Surakshit Matritva Aashwasan — an assurance of free, zero-expense, dignified and respectful care for every mother and newborn.

These mark India's strategic shift: the next lives to be saved depend less on coverage and more on quality and respect.

Programme	Mechanism
LaQshya	Labour-room and maternity-OT standards, assessed and certified
SUMAN	A public assurance of free, dignified care, with a grievance route
Maternal Death Surveillance and Response	Every death reviewed, no-blame, findings acted on
Kayakalp / NQAS	Facility quality certification, incentive-linked

These target the delay that money alone cannot fix. Delay three is about rosters, supervision and behaviour, none of which respond to a cash transfer.

Certification programmes carry a known risk: facilities prepare for the assessment rather than change practice. Look for whether standards hold on an unannounced night visit.

ImpactMojoMaternal Health 101www.impactmojo.in

The Progress

India's MMR has fallen markedly

Maternal Mortality Ratio, India (per 100,000 live births)

SRS Special Bulletins on Maternal Mortality; values illustrative of the well-established declining trend

A steep, sustained decline per the SRS — India has roughly crossed the SDG-aligned national threshold, though several states still lag well behind.

MMR, India (SRS)	Per 100,000 live births
2004–06	Around 250
2016–18	Around 113
2019–21	Around 93

The Sample Registration System is the authoritative source, published as Special Bulletins on Maternal Mortality. It samples rather than counts, so each figure carries a confidence interval and small-state estimates are unstable.

A decline this size is a real achievement — and it means the remaining deaths are the harder ones, in the districts and groups the first wave of gains missed.

ImpactMojoMaternal Health 101www.impactmojo.in

Unfinished Agenda

Progress is real, but uneven

The national average improves while the gaps persist: high-burden states, poorer districts, and marginalised groups still face MMRs far above the target.

The next phase is about equity and quality: reaching the last women, in the hardest places, with care that is not only available but good and respectful.

What improved fastest	What has not
Institutional delivery	Postnatal contact within 48 hours
ANC registration	Full ANC with every component delivered
The national MMR	The spread between states and districts
Access to a facility	Quality and dignity inside it

Every item in the left column responds to coverage; every item on the right responds to quality. That is the transition India is in, and it is the harder half.

For anyone designing a programme now: the marginal life saved is unlikely to come from another percentage point of institutional delivery. It comes from readiness on the night shift and from the districts nobody reports on.

ImpactMojoMaternal Health 101www.impactmojo.in

Measuring It

How we know if we are winning

Indicator	What it tells you	Source
MMR	Deaths per 100,000 live births	SRS
Institutional delivery (%)	Where women give birth	NFHS / HMIS
4+ / 8 ANC contacts (%)	Antenatal coverage	NFHS
Skilled birth attendance (%)	Who attends the birth	NFHS
Maternal death review	Why each death happened	Facility / community MDR

Counting deaths is not enough — maternal death reviews ask why each one happened, turning numbers back into the three delays you can fix.

Source	Strength	Limitation
SRS	The authoritative MMR	Sampled; lags by years; unstable for small states
NFHS	Rich, disaggregated, comparable	Every five years or so; self-reported
HMIS	Monthly, facility-level	Counts services, not outcomes; reporting incentives
MDSR	Explains why each death happened	Under-reporting where review feels punitive

Never assess a programme on HMIS alone. It is the only monthly source and the one most exposed to reporting pressure, because the people entering the numbers are judged on them.

Triangulate: HMIS for trend, NFHS for level and equity, SRS for mortality, MDSR for causation. Where they disagree, the disagreement is usually the finding.

ImpactMojoMaternal Health 101www.impactmojo.in

To find	Go to
India’s MMR, national and by state	SRS Special Bulletins on Maternal Mortality
Coverage and equity, disaggregated	NFHS-5 national, state and district fact sheets
What a scheme entitles a woman to	MoHFW guidelines for JSY, JSSK, PMSMA, LaQshya, SUMAN, HBNC
Clinical standards	WHO recommendations on antenatal, intrapartum and postnatal care
The three-delays framework	Thaddeus & Maine (1994)