Why one in two pregnancies in India is high-risk | Explained

An analysis by researchers from the Indian Council of Medical Research (ICMR) and the National Institute for Research in Reproductive and Child Health, Mumbai, has found a startling reality - nearly half of all pregnancies in India can now be classified as high-risk. The findings, drawn from the National Family Health Survey-5 (NFHS-5), shed light on a pressing public health concern with far-reaching consequences.

Considering that roughly 3 crore women in India experience pregnancy each year, and about 2.7 crore have live births, India continues to have the highest number of births globally. When nearly half of these pregnancies carry elevated medical risks, the implications are enormous, potentially influencing maternal and neonatal morbidity and mortality at a massive scale.

Why is it alarming?

The study revealed that the overall prevalence of high-risk pregnancies (HRP) among Indian women is 49.4 per cent. Of these, 33 per cent had a single high-risk factor, while 16.4 per cent had multiple high-risk pregnancies. Certain states exhibited even higher prevalence - Meghalaya reported 67.8 per cent, and Manipur 66.7 per cent of pregnancies with one or more high-risk factors.

According to the analysis, “nearly one-third of Indian pregnant women had at least one high-risk factor and sixteen per cent of women had multiple-high risks.”

Some of the most common high-risk factors included short birth spacing, adverse birth outcomes, and previous caesarean deliveries. About 31.1 per cent of women experienced short birth spacing, and 19.5 per cent had adverse outcomes during their previous pregnancies. Logistic regression analysis highlighted that women with no education had more than twice the odds of high-risk pregnancy, and those in the poorest wealth quintile also faced significantly higher odds. 

As per the government data, “India has made commendable progress in reducing maternal mortality, with the MMR declining from 130 per 100,000 live births in 2014-16 to 97 per 100,000 live births in 2018-20. This decline can be attributed to various government initiatives, improved healthcare access, and better medical interventions.” 

However, this study highlighted that “India is still far from meeting the Sustainable Development Goal of reaching below 70 deaths per 100000 live births by 2030.”

Factors contributing to high-risk pregnancies

The prevalence of high-risk pregnancies (HRP) in India is driven by a complex interplay of maternal, lifestyle, medical, and obstetric factors. According to the analysis, “The primary outcome of the study was high-risk pregnancies, i.e., pregnant women who had either one or more high-risk factors and were classified based on the PMSMA guidelines.” Using NFHS-5 data, the researchers identified several key contributors to HRP, including maternal age extremes—adolescent pregnancies between 15 and 17 years and advanced maternal age above 35 years, short stature below 140 cm, and high body mass index (BMI ≥30 kg/m²). Lifestyle factors such as regular smoking, use of tobacco products, and alcohol consumption were also associated with higher risks. Medical conditions like severe anaemia (Hb <7 g/dl) and comorbidities, including diabetes, hypertension, chronic respiratory diseases, thyroid disorders, heart disease, cancer, and kidney disorders, further compounded the risk among pregnant women.

Previous birth outcomes played a significant role as well. Women with higher birth orders, short or excessively long inter-pregnancy intervals, histories of preterm deliveries, adverse birth outcomes such as miscarriage, abortion, or stillbirth, and prior caesarean sections were classified as high-risk. 

The researchers noted that “the short birth spacing was the primary factor contributing to the high prevalence of high-risk pregnancies across the country. The major problem of short-birth spacing was that half of the Indian women were not using contraception to delay their next pregnancy.”

Socioeconomic and educational disparities further exacerbate the situation. Pregnant women from the poorest wealth quintiles or with no formal education were found to have significantly higher odds of being classified as high-risk. Additionally, regional differences were observed in risk factors: “Women in southern states were more likely to experience high-risk and multiple-high-risk than those in northern states, and it could be due to the higher frequency of women with obesity, comorbidities, short birth spacing and more in caesarean section delivery.” Other contributors included poor maternal nutrition, pregnancy-induced hypertension, and a history of obstetric complications, all of which are closely linked to low birth weight, neonatal malnutrition, and increased maternal and neonatal mortality.

The study emphasises the urgent need for comprehensive interventions targeting high-risk pregnancies. “Effective primary care referral systems will aid in the early detection of high-risk conditions, which will help to provide early management and quality obstetric care for complicated pregnancies,” the authors stated. They further highlighted that multidisciplinary care involving obstetricians, maternal-fetal medicine specialists, cardiologists, diabetologists, and mental health professionals is essential, particularly for women with comorbidities. Additionally, empowering Accredited Social Health Activists (ASHAs) to counsel couples on birth spacing and monitor high-risk pregnancies can improve maternal and neonatal outcomes. 

Strengths and limitations of the analysis

The study’s strengths lie in its large, nationally representative sample size and diversity, which allows for more precise identification of sociodemographic and geographic groups where high-risk pregnancies are concentrated. According to the researchers, this “is important from the policy and programme perspectives.”

The study also offers insight into regional disparities, highlighting areas requiring focused interventions, and enabling better allocation of healthcare resources. Additionally, it identifies the most pressing high-risk factors, such as short birth spacing and prior to adverse pregnancy outcomes, to inform targeted public health strategies.

However, the study has certain limitations. The analysis did not include pregnancy-related complications such as gestational diabetes mellitus, multiple gestations, and infections during the current pregnancy. Information on mode of delivery and gestational age at delivery for women with longer birth spacing was also unavailable. Some health issues, including hypertension and respiratory diseases, were self-reported and may have been undiagnosed. Furthermore, smaller sample sizes in certain states and union territories may have contributed to disproportionately high prevalence estimates.

What steps are taken by the government 

The Indian government has implemented several initiatives to improve maternal and neonatal health, particularly for high-risk pregnancies. “The Ministry of Health and Family Welfare (MoHFW) supports all States/UTs in implementation of Reproductive, Maternal, New-born, Child, Adolescent health and Nutrition (RMNCAH+N) strategy under National Health Mission (NHM) based on the Annual Programme Implementation Plan (PIP) submitted by States/ UTs to reduce MMR & Neonatal Mortality Rate.” 

Programs like Janani Suraksha Yojana (JSY), Pradhan Mantri Matru Vandana Yojana (PMMVY), and Janani Shishu Suraksha Karyakaram (JSSK) promote institutional deliveries, provide financial support, and reduce out-of-pocket expenses, especially for women from vulnerable communities. Initiatives such as Surakshit Matritva Aashwasan (SUMAN) ensure dignified and quality care for all pregnant women and newborns.

Targeted schemes also address high-risk pregnancies directly. “Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) provides pregnant women a fixed day, free of cost assured and quality Antenatal Care on the 9th day of every month,” along with additional follow-ups by ASHAs for high-risk cases. 

LaQshya focuses on improving labour room and maternity operation theatre care, while capacity-building programs train doctors in anaesthesia and obstetric skills, especially in rural areas. Programs like Maternal Death Surveillance Review (MDSR) and Monthly Village Health, Sanitation, and Nutrition Day (VHSND) strengthen community-level monitoring and preventive care.

Infrastructure improvements further support maternal care. Comprehensive Abortion Care services, delivery points, First Referral Units, and Maternal and Child Health Wings have been upgraded, while “operationalisation of Obstetric ICU/HDU at high case load tertiary care facilities across country to handle complicated pregnancies” ensures advanced medical attention. 

Digital tracking through the Reproductive and Child Health (RCH) portal, along with distribution of MCP Cards and Safe Motherhood Booklets, and awareness campaigns like Anaemia Mukt Bharat, collectively aim to reduce maternal and neonatal mortality.

This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.