‘This year, we hope to have zero maternal deaths’: India’s south makes giving birth safer

CHENNAI – Dr Teres Cuba looked at a mother who had just given birth to a baby, lying on the stretcher. A nurse yelled that she was losing blood quickly.

“Her blood pressure and pulse rate are dropping!” someone else shouted. 

Realising this was a case of postpartum haemorrhage, Dr Cuba asked the nurse to administer oxytocin, massaged the patient’s uterus and checked for continued bleeding. The mother’s life was ultimately saved. 

That the mother on the stretcher was a mannequin, and that this was a simulation exercise in a training programme to handle obstetrics emergencies, did not diminish Dr Cuba’s sense of achievement. 

“I want to be as good as I can get at dealing with obstetric emergencies – practice makes perfect,” the 38-year-old said.

As a medical officer in a primary healthcare centre in Paramakudi block in Ramnathapuram district of Tamil Nadu, she is at the front line of the state’s drive to improve maternal health outcomes.

The training Dr Cuba and her colleagues took part in in November was organised by Singapore’s healthcare group SingHealth and non-profit Singapore International Foundation (SIF). The local doctors and nurses are expected to share their learnings with other healthcare workers throughout the state. 

Mission-minded doctors like Dr Cuba have bolstered Tamil Nadu’s drive to eliminate maternal deaths during childbirth. 

The state in India’s south has steadily shrunk maternal mortality in the past decade, now recording 35 deaths per 100,000 live births. This is the second-best performance in India after Kerala and Andhra Pradesh, both at 30 deaths per 100,000 live births. 

Including Telangana and Karnataka, the average maternal mortality in these five southern states is 42 – far lower than India’s average of 88.

While maternal death rates are on the decline in states like Madhya Pradesh, Odisha, Uttar Pradesh and Assam, they are still above 100.

For the southern outlier states, the secret sauce is an unglamorous systemic focus on maternal health.

Having more doctors, nurses, training courses, medical centres and equipment and ambulances, has made a difference, as have grassroots awareness campaigns.

In addition, socio-economic advantages like better women’s education, family support, sanitation and good roads have contributed to this track record, thanks to decades-old governance priorities of the southern states. 

Officials in southern states told ST that underperforming regions could save more mothers’ lives, too – if they have the political will and persistently apply existing protocols.

“There are more than 100 child deliveries in our centre every month, and high-risk situations happen regularly,” said Dr Cuba.

Her heart is still heavy about a 28-year-old pregnant woman who died in childbirth in 2024 in her district. 

“She was the only mother we lost in 2024, but even one death is unacceptable. This year, we hope to have zero deaths. We should be ready for every emergency,” she added. 

Best practices

More than 3.7 million babies were born in the five southern states in 2024. After decades of reducing fertility rates, which are now the lowest in the country at around 1.5 to 1.6 children per woman, the states have been turning their attention to preventing maternal deaths.

Since 2002, Kerala has confidentially reviewed maternal deaths – including those at private hospitals – with a “no name, no blame” approach, to identify and address the factors like lack of training or delayed support that led to the fatalities.

Andhra Pradesh’s Health Minister Y. Satya Kumar said central government funds have gone towards improving labour rooms, establishing special delivery wings in busy facilities, and conducting antenatal courses taken up by 70 per cent of expectant mothers.

Tamil Nadu has seen improvements by “properly implementing existing national protocols and augmenting it with state-level schemes”, said Dr J. Nirmalson, joint director of the state’s department of public health and preventive medicine (maternal and child health). 

Tamil Nadu’s initiatives range from technological upgrades to old-school welfare policies. 

Since 2005, the Tamil Nadu Health Systems Project set up Comprehensive Emergency Obstetric and Neonatal Care Centres with dedicated round-the-clock staff and facilities in 120 secondary care and 38 tertiary care institutions. 

Out of around 903,000 deliveries in Tamil Nadu in 2024, almost 100 per cent happened at hospitals, Dr Nirmalson said. 

The state of 72 million people also conducts eagle-eyed household monitoring to encourage hospital births rather than home births. Pregnant women get 18,000 rupees (S$262) including nutrition kits aimed at preventing anaemia, and all pregnant women get special digital IDs to track their medical check-ups and highlight any high-risk factors.

Mothers die during or after childbirth in India primarily due to excessive bleeding after childbirth, pregnancy-related infection or convulsions from high blood pressure (eclampsia).

So, the state has been regularly training its doctors, nurses and midwives to identify, plan for and act on high-risk pregnancies, which tend to get neglected in state hospitals, which are often under-equipped and under-staffed to cope with swarms of patients. 

Regular training

SingHealth and SIF have worked with the Tamil Nadu government for a decade to hold workshops to enhance maternal and child health services. Doctors and nurses trained in these sessions help to amplify the impact by training colleagues in the state.

“Our special focus has been to train obstetricians, gynaecologists, nurses and midwives to be prepared for pregnancy emergencies and review the protocols across primary, secondary, and tertiary healthcare institutions,” said Ms Corinna Chan, CEO of SIF. 

Doctors and senior nurses from Singapore’s KK Women’s and Children’s Hospital and SingHealth Polyclinics volunteered to conduct trainings in Tamil Nadu in two phases in 2015-2018 and 2023-2025.

Dr Shephali Tagore has been the chief trainer in the Singapore-Tamil Nadu collaboration.

The senior consultant in maternal and foetal medicine in KK Women’s and Children’s Hospital explained that maternal mortality in Singapore is only six for every 100,000 births – “not just because of modern equipment but also because Singaporean mothers have help-seeking behaviour, while in India, community health workers have to convince mothers to come for regular check-ups”. 

A major contributor to maternal mortality in India is that rural or low-income patients go to the nearest primary healthcare centres (the bottom layer of a three-tier system). These centres can conduct deliveries, but have to transfer high-risk patients to secondary or tertiary care hospitals that have the specialists and equipment to conduct emergency operations.

To prevent deaths during transfer, Tamil Nadu developed a unique, robust referral protocol.

“The lean staff at the primary healthcare centres – a medical officer, a nurse and a helper – first quickly identify a high-risk pregnancy,” said Dr M. Mahalakshmi, an obstetrics professor and trainer from Chennai.

While they stabilise the patient, they alert the nearest secondary or tertiary centre, she said.

“So, the ambulance comes faster, and when the mother gets to the hospital, the doctors there are ready with the blood group and medical history. There is no delay in treatment.”

Tamil Nadu has also found a neat solution to a longstanding challenge: reaching minor, unwed and aged mothers, who often hide their pregnancies due to social stigma.

The online registration system for mothers has been tweaked to give a mother a temporary digital ID instead of a permanent one if her age is under 18 or she does not mention her husband’s name. 

The digital fix that sidesteps cultural shame to extend healthcare to more mothers is just another example of small, humane tweaks to a colossal health system to save women’s lives. 

The state has made strides in maternal healthcare, but Dr Nirmalson acknowledged that there is still work to do.

“Some pregnant women are not on our radar because they do not come for check-ups, due to lack of awareness, having to work, or having other children to care for. Sometimes, they don’t have anyone to take them to the hospital,” he said.