Uncertainty about maternal mortality in India: New, higher estimates from the National Family Health Survey-4

Background: Mortality rates in India shape global statistics, including about the United Nations’ (UN) Sustainable Development Goals (SDGs). SDG 3 sets a target global maternal mortality ratio (MMRatio) of fewer than 70 maternal deaths per 100,000 live births by 2030. However, because vital registration is incomplete, maternal mortality rates in many countries including India are based on indirect estimates, data from mortality surveillance sites, or household surveys. Objective: This paper presents empirical national and regional maternal mortality estimates for India using National Family Health Survey-4 (NFHS-4) data. We compare the findings to existing estimates of maternal mortality made using the Sample Registration System (SRS), a nationally representative network of demographic surveillance sites, and the UN. Results: Building on a recent literature measuring maternal mortality based on household reports of deaths of recent members, we calculate a MMRatio from the NFHS. We estimate 228 maternal deaths per 100,000 live births for 2012-16 (95% CI: [204, 266]). In contrast, the SRS reports an MMRatio of 130 for 2014-16. The difference in the total number of maternal deaths in India implied by the NFHS rather than the SRS is greater than the total number of maternal deaths in any country except Nigeria. We find that differences between the NFHS and the SRS are largest in the Empowered Action Group states of north India. We use demographic decomposition to show that the difference between the NFHS and the SRS is mostly accounted for by not classifying adult female deaths as maternal, rather than by not detecting deaths at all. However, the NFHS also finds higher all-cause mortality among women of childbearing age than does the SRS. As we detail, some aspects of the NFHS results raise issues of data quality for its maternal mortality information, which must be weighed against questions of data quality for the SRS and other sources. Contribution: If the NFHS-4 maternal mortality figures are correct, it would imply that, rather than being on track to meet SDG 3, India needs urgent additional investment in maternal health, particularly in the poorer Empowered Action Group states.