Meta-analysis on maternal deaths and assessing significant factors for heterogeneity between states of India during 2016




MM, MMR, Meta-analysis, ANC visits, India


Objective of the study was to provide a more precise estimate of maternal mortality (MM), maternal mortality ratio (MMR) and to identify significant factors contributing for heterogeneity between the states in India. “Metaprop” procedure in STATA software, which are specific to binomial data was applied on state wise MM data published by sample registration system (SRS) during 2014-16. An overall MM estimate and potential sources of heterogeneity could be identified using meta-regression. Corrected estimates of MMR by states were compared. SRS published the MM data by 17 Major states. Overall reported MM was 8.8 per 100, 000 women. Estimate obtained by random effect model was 8.3 (95% CI: 5.9-11.1) per 100,000 women. Heterogeneity between states was very high (I2-statistics =91.9%), and egger regression revealed no reporting bias (p=0.672). Meta-regression analysis indicated that the percent women attending full antenatal care (ANC) visits found to be highly significant (p<0.001) for MM with inverse relationship implying that the states with a higher percentage of women with full ANC visits are likely to have lesser MM. While the estimate of MMR by SRS was 130 per 100,000 live births, corrected MMR was 123 (95% CI: 87-164) accounting for 26% reduction from previous estimate 167 obtained in 2013. This paper provided a precious estimate of both MM and MMR adjusted for sampling weight. Further, the importance of either full ANC visits or four ANC visits could be demonstrated for reduction in MMR on achieving the Millennium development goal (MDG) in the country.


Author Biography

Vanamail Perumal, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Additional Professor of Statistics & Demography

Obstetrics & Gynaecology


Hogan MC, Foreman KI, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal mortality for 181 countries, 1980-08: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609-23.

Chatterjee A, Paily VP. Achieving Millennium Development Goals 4 and 5 in India. BJOG. 2011;118(2):47-59.

Trends in Maternal Mortality: 1990 to 2008. Estimates developed by WHO, UNICEF, UNFPA and The World Bank. World Health Organisation, 2010. Available at: Accessed on 10 Jan 2020.

Rai RK, Tulchinsky TH. Addressing the sluggish progress in reducing maternal mortality in India. Asia Pac J Public Health. 2015;27(2):NP1161-9.

Census of India-Vital Statistics-Sample Registration System. Available at: Accessed on 10 Jan 2020.

Special bulletin on maternal mortality in India 2014-16. Available at: Accessed on 2018 Feb 26

National Family Health Survey 2015-16 (NFHS-4)-state fact sheet.pdf. Available at: Accessed on 2018 Feb 26.

Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014;72:39.

Hunter JP, Saratzis A, Sutton AJ, Boucher RH, Sayers RD, Bown MJ. In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias. J Clin Epidemiol. 2014;67:897-903.

Annual Report 2017-18. Ministry of Health and Family Welfare, Government of India. Available at: Accessed on 10 Jan 2020.

Kansal A, Kandpal SD. India’s Story of Reducing Maternal Mortality-Achievement so far and Commitments Ahead. Indian J Comm Health. 2018;30(2):107-10.

Kumutha J, Chitra N, Vidyasagar D. Impact of implementation of NRHM program on NMR in Tamil Nadu (TN): a case study. Indian J Pediatr. 2014;81(12):1358-66.

Shah P, Shah S, Kutty RV, Modi D. Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5. Trop Med Int Health. 2014;19(5):568-75.

Gupta SK, Pal DK, Tiwari R, Garg R, Shrivastava AK, Sarawagi R et al. Impact of Janani Suraksha Yojana on institutional delivery rate and maternal morbidity and mortality: an observational study in India. J Health Popul Nutr. 2012;30(4):464-71.

Randive B, Diwan V, De Costa A. India’s Conditional Cash Transfer Programme (the JSY) to Promote Institutional Birth: Is There an Association between Institutional Birth Proportion and Maternal Mortality? PLoS one. 2013;8(6):e67452.

Randive B, San Sebastian M, De Costa A, Lindholm L. Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: results from nine states in India. Soc Sci Med. 2014;123:1-6.

Mahala U, Mehta S. Maternal health outcomes following the implementation of Janani Shishu Suraksha Yojana (JSSY) at a tertiary healthcare center in Rajasthan. Int J Gynaecol Obstet. 2017;139(3):297-300.

Kumar V, Kumar A, Das V, Srivastava NM, Baqui AH, Santosham M et al. Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India. Int J Gynaecol Obstet. 2012;117(1):48-55.

Ghosh A. Inequality in maternal health-care services and safe delivery in eastern India. WHO South East Asia J Public Health. 2015;4(1):54-61.

Telecom Regulatory Authority of India, New Delhi. 2017;43. Available at: Accessed on 11 Jan 2020.