Published Jan 31, 2026 | 9:06 AM ⚊ Updated Jan 31, 2026 | 9:06 AM
Even in high-risk cases, timely identification and sustained care helps women deliver healthy babies. Pictured, 'Mother and Child' by Patricia Finch.
Synopsis: While states with high maternal mortality faced risks rooted in poverty and limited healthcare access, South India’s risk profile reflected an epidemiological shift driven by prosperity and urbanisation rather than economic deprivation.
Nearly one in two pregnancies in South India carries at least one high-risk factor. However, the region reported significantly lower maternal mortality than states with fewer risky pregnancies.
The finding is based on a national survey-based analysis that attributed the survival advantage to superior healthcare infrastructure and institutional delivery systems.
The study, based on data from the National Family Health Survey-5 and published in the Journal of Global Health, found that 49.7 percent of pregnancies in southern Indian states fell in the high-risk category, closely matching the national average of 49.4 percent.
What distinguished the southern states was the higher proportion of women with multiple high-risk factors — at 18.6 percent — compared with 16.4 percent nationally.
Despite these elevated numbers, maternal deaths remained substantially lower in South India than in many northern and central states, creating a striking paradox that underscored the critical role of healthcare quality over risk prevalence.
States with fewer high-risk pregnancies (HRPs), such as Odisha (37.3%), Chhattisgarh (38.1 %), and Assam (41%), continued to report higher maternal deaths. In contrast, southern states recorded more high-risk cases but had better survival outcomes.
Researchers attributed this survival advantage to stronger health systems, better referral networks, and wider access to institutional deliveries in southern states, which managed complications before they became fatal.
“Several states have high HRP rates, but due to the continuum of care and excellent quality treatment, the maternal mortality rate is lower than in those with lower prevalence of HRP states. This suggests that improving the quality of obstetric care and medical health facilities in the states lead to way forward in the reduction of IMR and MMR,” the authors said.
The research emphasised that effective primary care referral systems led to the early detection of high-risk conditions. It helped in providing early management and quality obstetric care for complicated pregnancies.
A multidisciplinary team of obstetricians, maternal-foetal medicine specialists, cardiologists, nephrologists, diabetologists and psychologists were necessary for providing care to high-risk pregnant women, particularly those with illnesses such as diabetes, hypertension, heart disease and mental health disorders.
While states with high maternal mortality faced risks rooted in poverty and limited healthcare access, South India’s risk profile reflected an epidemiological shift driven by prosperity and urbanisation rather than economic deprivation.
In Andhra Pradesh, Telangana, Tamil Nadu and Kerala, high-risk pregnancies were increasingly driven by short birth spacing, high caesarean section rates, obesity and pregnancy-related comorbidities like hypertension and diabetes.
“A high-risk pregnancy refers to the mother, the foetus, or both face a higher-than-normal likelihood of complications during pregnancy, childbirth, or the period after delivery. Doctors classify it as high risk when the woman needs closer medical supervision, frequent check-ups, or specialised intervention to prevent harm,” said Dr Ch Kavya, a Hyderabad-based gynaecologist and obstetrician.
She explained that high-risk classification might arise due to factors such as pregnancy in teenagers or women above 35 years, short birth spacing, severe anaemia, obesity or very low or high body mass index, high blood pressure, diabetes, thyroid, heart or kidney disease, chronic infections or cancer. Obstetric histories that included multiple previous births, caesarean sections, preterm deliveries, or miscarriage and stillbirth, too, contributed to high-risk cases.
“Though it is important to note that a high-risk label does not mean something will inevitably go wrong, as timely identification and sustained care allow many women to deliver healthy babies,” Dr Kavya added.
Telangana recorded one of the highest prevalence of high-risk pregnancies in the country at 60.3 percent, with 26.2 percent of women facing multiple high-risk factors. Andhra Pradesh followed with 54.5 percent overall prevalence and 26.6 percent with multiple risks.
Tamil Nadu reported 53.9 percent of pregnancies as high-risk, with 15.4 percent carrying multiple risk factors. Kerala, despite its reputation for strong healthcare outcomes, showed 46.8 percent high-risk pregnancies and 12.6 percent with multiple risks. Karnataka recorded 46.5 percent and 13.7 percent, respectively.
Andhra Pradesh faced an especially acute challenge with short birth spacing. Nearly half of pregnant women in the state, 48.1 percent, had gaps of less than 18 months between births, the highest rate recorded across all Indian states and Union Territories. This exceeded the national average of 31.1 percent for short birth spacing.
The analysis revealed a counterintuitive pattern in the south. Education and income offered limited protection against pregnancy risks in the region.
Women from wealthier and better-educated households, too, faced elevated risks due to delayed childbearing, repeat caesarean deliveries, and lifestyle-related conditions associated with urbanisation.
“Women under the lowest wealth quintiles and no education were the independent predictive factors of HRP,” the study said.
“Women in southern states were more likely to experience high-risk and multiple high-risk events than those in northern states. It could be due to the higher frequency of women with obesity, comorbidities, short birth spacing and more in caesarean section delivery,” the study found.
Caesarean sections played a major role in the south’s risk landscape. Southern states consistently reported higher surgical delivery rates, which increased the likelihood of complications in subsequent pregnancies, especially when birth intervals remained short.
The study found that 16.4 percent of women nationally had undergone a caesarean section in their most recent delivery, but the rate was significantly higher in southern states. In Ladakh and Puducherry, caesarean delivery rates reached 50 percent each, while southern states showed similarly elevated patterns.
A systematic review showed that women who had previous caesarean deliveries within a shorter duration from the previous birth were at increased risk of uterine rupture, blood transfusions, and maternal morbidity. A shorter inter-pregnancy interval was closely associated with premature rupture of membranes, abruptio placentae, placenta praevia, and uterine rupture in women with previous caesarean deliveries.
The study also linked obesity and metabolic disorders, more prevalent in the south, to higher odds of pregnancy complications and medical intervention.
The research found that over four percent of women nationally had a higher body mass index, and more than six percent of women reported having comorbidities during their current pregnancies. In Goa, 17.4 percent of pregnant women had a higher BMI, the highest in the country.
Obesity is associated with a greater risk of developing gestational diabetes, cardiovascular disease, venous thromboembolism, and infections, particularly in older women, and these mothers have a higher risk of perinatal fatalities.
Increased BMI and excessive gestational weight gain during pregnancy were found to be associated with the infant’s birth weight, also developing preeclampsia in women, and requiring more birth interventions like caesarean delivery.
Comorbidities, or pregnancy-related complications, were attributed to the greatest risk of maternal deaths. Bad obstetric history, pregnancy-induced hypertension, anaemia, and poor maternal nutrition were other main factors associated with high-risk pregnancies, which led to low birth weight and infant malnutrition.
Nearly one in five women nationally, 19.5 percent, reported a history of adverse birth outcomes such as miscarriage, abortion or stillbirth. The study noted that women who reported caesarean sections were found in 16.4 percent of the last birth outcomes.
Other high-risk factors included women having longer spacing at 15.8 percent, a history of preterm delivery at 14.1 percent, and comorbidities at 6.4 percent.
The study held high-risk pregnancies responsible for 75 percent of perinatal deaths in India. The under-five mortality rate for shorter birth intervals was reported to be twice as high as the rate for birth intervals of three or more years.
The findings suggested that South India was facing a different maternal health challenge than states struggling with basic access to care. The task went beyond expanding access to institutional deliveries, but involved preventing avoidable risk through better birth spacing, tighter regulation of caesarean deliveries, and early management of chronic conditions among women of reproductive age.
Without addressing these trends, the study warned, the region risked normalising medically complex pregnancies even as overall maternal survival improves.
The research emphasised that every pregnant woman should utilise the government’s health facilities and maternal health care services, which included a comprehensive antenatal care package, prenatal counselling, newborn care, breastfeeding support and emergency obstetric and newborn care facilities.
The study suggested empowering Accredited Social Health Activists (ASHAs) who would assist and counsel couples for delaying the period from one birth to another, and they could also do regular follow-up of high-risk pregnant women for safe delivery at referral healthcare facilities.
The research was based on data from 23,853 pregnant women aged 15 to 49 across all states and Union Territories, analysed as part of the National Family Health Survey-5.
(Edited by Majnu Babu).
