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Original research
Risk factors for maternal mortality among 1.9 million women in nine empowered action group states in India: secondary analysis of Annual Health Survey data
  1. Geneviève Horwood1,
  2. Charles Opondo1,
  3. Saswati Sanyal Choudhury2,
  4. Anjali Rani3,
  5. Manisha Nair1
  1. 1Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Department of Obstetrics and Gynaecology, Gauhati Medical College and Hospital, Guwahati, Assam, India
  3. 3Department of Obstetrics and Gynaecology, Banaras Hindu University Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
  1. Correspondence to Dr Manisha Nair; manisha.nair{at}


Objective To examine the risk factors for pregnancy-related death in India’s nine Empowered Action Group (EAG) states.

Design Secondary data analysis of the Indian Annual Health Survey (2010–2013).

Setting Nine states: Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand.

Participants 1 989 396 pregnant women.

Methods Maternal mortality ratio (MMR), overall and for each state, with 95% CI was calculated. Stepwise multivariable logistic regression was used to investigate the association of risk factors with maternal mortality. Area under the receiver-operating characteristic (AUROC) curve was used to assess the prediction of the model.

Outcome measures MMR adjusted for survey design, adjusted OR (aOR)with 95% CI and C-statistic with 95% CI.

Results MMR calculated for the nine states was 383/100 000 live births (95% CI 346 to 423 per 100 000). Age exhibited a U-shaped association with maternal mortality. Not having a health scheme and belonging to a scheduled caste or scheduled tribe group were significant risk factors for maternal death with aOR of 2.72 (95% CI 2.41 to 3.07), 1.10 (95% CI 1.02 to 1.18) and 1.43 (95% CI 1.31 to 1.56), respectively. Socioeconomic status and rural residence were not associated with maternal mortality after adjusting for access to a healthcare facility. Complications of pregnancy and medical comorbidities were the strongest risk factors for maternal death (aOR 50.2, 95% CI 44.5 to 56.6). Together, the risk factors identified accounted for 89% (95% CI 0.887 to 0.894) of the AUROC.

Conclusions Maternal mortality in India’s EAG states greatly exceeds the national average. The identified risk factors demonstrate the importance of improving the quality of pregnancy care. Notably, the study showed that the risk conferred by poor socioeconomic status could be mitigated by universal access to healthcare during pregnancy and childbirth.

  • epidemiology
  • obstetrics
  • public health

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors GH reviewed the literature, conducted the analysis and wrote the first draft of the paper; CO supervised the data analysis, interpretation and discussion of the results, and edited the paper; SSC helped in acquiring and interpreting the data, and edited the paper; AR edited the paper; MN developed the concept for the study, supervised the data analysis, interpretation and discussion of the results, and edited the paper.

  • Funding The study was funded by a Medical Research Council Career Development Award to Manisha Nair (Grant Ref: MR/P022030/1). The funder had no role in the study design, data analysis, data interpretation or writing of the manuscript. All authors, had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval was not required since this was a secondary analysis of anonymous survey data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. The anonymised data is freely available through the Indian Government’s Data Sharing Portal.

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