The Impact of “Mother” Project on Maternal & Child Health Indicators of Meghalaya

Background of the Study

Meghalaya, a north-eastern Indian state with a unique matrilineal social structure, has historically grappled with alarming maternal and child health disparities. Despite progressive gender norms, the state lagged behind national and global benchmarks, reporting a maternal mortality ratio (MMR) of 197 deaths per 100,000 live births as per the demographic survey SRS 2016-18.  The infant mortality rate (IMR) of 30 deaths per 1,000 live births as per NHFS-4, 2015-16.  Key challenges included low institutional delivery rates (51.4% rural), inadequate antenatal care (ANC) compliance (49.6% rural), and systemic barriers such as geographic inaccessibility, cultural preferences for home births, and fragmented intersectoral coordination.

“MOTHER” Project

The Government of Meghalaya launched the MOTHER Project in 2019, a holistic policy initiative aligned with the National Health Policy, 2017, and the Sustainable Development Goals (SDGs). The project integrates three dimensions of healthcare—preventive, curative, and enabling—through innovations such as the MOTHER App (real-time pregnancy tracking), the Chief Minister’s Safe Motherhood Scheme (CM-SMS) (transportation incentives), and Village Health Councils (VHCs) (community-led governance).

Public Health Context and Significance of Indicators

Globally, the maternal mortality ratio (MMR) and infant mortality rate (IMR) are recognized by the World Health Organization (WHO) as primary metrics for evaluating healthcare access and quality. [World Health Organization, 2023] In India, institutional delivery rates and antenatal care (ANC) compliance are pivotal to reducing preventable deaths, with institutional deliveries alone reducing maternal mortality risks by 50%. [Singh et al., 2020] Similarly, immunization coverage directly impacts child survival, preventing 2–3 million annual deaths globally from vaccine-preventable diseases. [UNICEF, 2022] The National Family Health Survey (NFHS-5, 2019–21) and official reports document a steady decline in the maternal mortality ratio (MMR) and improvements in related care. India’s MMR fell from about 130 per 100,000 live births in 2014–16 to 97 in 2018–20 [Kumar, 2015], reflecting better access to emergency obstetric care and nutrition. Infant mortality has likewise declined, with approximately 35 infant deaths per 1,000 live births nationally in recent years (down from ~41 in 2015–16) [5]. National immunization coverage is now around 76%, meaning about three-quarters of children aged 12–23 months are fully immunized. At the same time, the use of maternal health services has increased: NFHS-5 reports that 70% of pregnant women registered for antenatal care (ANC) in the first trimester (up from 59% in 2015–16), and 89% of births now occur in health facilities (up from 79%) [Kumar, 2025]. About 59% of mothers achieved the recommended ≥4 ANC visits in NFHS-5 (up from 51%) [Kumar, 2025]. These gains, driven by initiatives such as Janani Suraksha Yojana and strengthened health systems, have improved maternal and child survival. However, India’s rates still lag behind global targets (SDG MMR<70; U5MR<25), and coverage gaps persist in rural and vulnerable communities. Nationally, one million under-five deaths still occur annually, many from preventable causes, including vaccine-preventable infections. In this context, indicators like MMR, infant mortality rate (IMR), institutional delivery rate, full immunization coverage, ANC coverage, and early pregnancy registration remain high priorities for health policy and monitoring.

Maternal Mortality Ratio

The MMR is the number of maternal deaths per 100,000 live births and is a key barometer of health system performance. Maternal deaths occur due to complications of pregnancy and childbirth, and reflect both the quality and accessibility of obstetric care. [ Goli & Jaleel, 2014]

Infant Mortality Rate

IMR – the number of deaths of infants (under 1 year) per 1,000 live births – is a sensitive indicator of child health and survival. In India, neonatal and infant mortality have declined in recent years, but still remain high in many regions. Vaccination, nutrition, and neonatal care are critical; nearly one million Indian children die before age five each year, and many of these deaths could be prevented through immunization and other basic services. [Visaria, 1985] High IMR indicates gaps in newborn care, immunisation, sanitation, and maternal health (since maternal health strongly affects newborn outcomes).

Institutional Delivery

The proportion of births occurring in health facilities (with skilled attendants) is a vital measure of maternal and newborn safety. Institutional deliveries are generally associated with lower maternal and neonatal mortality, because healthcare facilities provide emergency obstetric care, skilled attendance, and referral in case of complications. [ Tura et al., 2013] In practice, states with higher institutional delivery rates (e.g. Kerala at ~100%) have far lower MMR and IMR than those where many births occur at home. Increasing facility-based delivery is thus a cornerstone of maternal-child health programs.

Immunization Coverage

Full immunization of children (completion of all recommended vaccines by age 1) is critical to prevent childhood diseases and deaths. India’s Universal Immunization Programme is one of the world’s largest, yet gaps persist. NFHS-5 reports about 76% of Indian children 12–23 months are fully vaccinated, meaning roughly one in four children still miss basic vaccines. Infections like pneumonia and diarrheal disease – major drivers of child mortality – can be largely prevented by vaccines (e.g. measles, pneumococcal, rotavirus). Therefore, high immunization coverage directly reduces both IMR and under-five mortality.

Antenatal care (ANC) coverage.

Women who receive four or more ANC visits have significantly better birth outcomes than those with inadequate care. In India, the proportion of women receiving 4+ visits has risen to 59% (NFHS-5), yet a large minority still miss this minimum. Monitoring ANC coverage thus signals how well the health system engages pregnant women and helps prevent both maternal and neonatal complications.

First Trimester Registration

Early registration of pregnancy (in the first 12 weeks) is an important ANC sub-indicator. WHO and national guidelines recommend first contact in the first trimester to begin timely care. [ World Health Organization, 2016] It allows earlier prophylaxis (e.g. immunizations, screening for infections) that improve pregnancy outcomes.

Meghalaya’s Public Health Status

Meghalaya’s maternal and child health indicators have historically lagged behind national averages and peer states. For example, 2015–16 data show Meghalaya’s infant mortality rate (~30 per 1,000) was well above Kerala’s and near the national level. Alarmingly, Meghalaya’s maternal mortality (MMR ~197) was among the highest in the country, over four times that of Kerala. Correspondingly, only about half of births were institutional (51.4% in 2015–16) [Government of Meghalaya, Directorate of Health Services, 2021] Child immunization was also very low: only ~61% of children aged 12–23 months were fully immunized in Meghalaya (NFHS-4) compared to ~76% nationwide. [IIPS & ICF, 2021] These shortfalls were among the worst in India – for instance, state documents noted Meghalaya was “lowest in terms of immunization rates” in 2018–19. Other north-eastern states faced similar gaps, but Meghalaya’s combination of high MMR/IMR and low service uptake stood out. Early NFHS-5 data confirm modest gains – for example, institutional delivery rose to ~58% (2019–21) [IIPS & ICF, 2021] Compared to benchmark states like Kerala or Goa (≈99% institutional delivery), Meghalaya’s 2019–20 situation underscored the need for focused health interventions. [Kumar & Das, 2020] Given these challenges – rugged terrain, limited health infrastructure, and socio-economic disadvantages – policy-level interventions have been prioritized in Meghalaya. Technology-driven tracking and community schemes are viewed as essential supplements to routine services. In 2019, the Meghalaya government launched the MOTHER (Measurable Outcomes in Transforming the Health Sector through a Holistic Approach with a Focus on Women’s Empowerment) program. This initiative employs a mobile health application to register pregnancies at first visit and to continuously monitor each expecting mother’s ANC, risk factors, and immunization through to delivery.  Launched in 2019, the project was bolstered by the Meghalaya Health Systems Strengthening Project (MHSSP), a $40 million initiative funded by the World Bank. This funding facilitated comprehensive reforms in the state's health sector, including the implementation of performance-based financing and the establishment of benchmarks to enhance accountability and service delivery. [Jagran Josh, 2021] Under the MHSSP, the state introduced Internal Performance Agreements (IPAs) between the Department of Health and Family Welfare and its subsidiaries, fostering greater accountability across all levels of the health system. These agreements have been instrumental in improving management capacity, quality, and utilization of health services in Meghalaya. For instance, an analysis of 46 health facilities revealed significant achievements, with average IPA scores increasing by 34% in Primary Health Centres and 36% in Community Health Centres, surpassing the target of 15%. [World Bank, 2021]

LITERATURE REVIEW

Maternal and child health (MCH) remains a cornerstone of global public health, with the Sustainable Development Goals (SDGs) targeting reductions in maternal mortality (MMR) to <70 per 100,000 live births and neonatal mortality to <12 per 1,000 by 2030. [World Health Organization, 2023] Despite progress, disparities persist: India’s MMR declined from 556 (1990) to 97 (2021), yet states like Meghalaya lagged with an MMR of 197 (2016–18), nearly double the national average. [Desai et al., 2025] Inequities stem from socioeconomic determinants, including poverty, gender dynamics, and infrastructural barriers, which necessitate multisectoral solutions. [Dutta et al., 2022].  Research consistently highlights significant disparities in maternal health service utilization and outcomes, particularly within socioeconomically disadvantaged regions like the Empowered Action Group (EAG) states. Studies utilizing national data (e.g., NFHS-4) demonstrate pronounced inequalities, where essential services like antenatal care (≥4 visits), institutional delivery, and contraception use are heavily concentrated among wealthier households, while unmet need for family planning is disproportionately higher among the poor. [Yadav et al., 2021] Kerala leads in maternal health service utilization, followed by Tamil Nadu, Andhra Pradesh, and Karnataka. Differences are linked to program implementation and accessibility. [ Navaneetham & Dharmalingam, 2002] Global policies to overcome maternal health challenges focus on reducing maternal mortality, improving access to quality care, and addressing social determinants of health.  The Sustainable Development Goals (SDG 3.1) aim to reduce global maternal mortality to <70 deaths per 100,000 live births by 2030, with no country exceeding 140. Despite a 40% decline since 2000, the 2023 global maternal mortality ratio (MMR) remains high at 197, far above the target. At the current annual reduction rate (2.9%), the world will miss the 2030 goal, requiring an accelerated reduction rate of ~15% annually—a pace rarely achieved. [Syed et al., 2022] However, a more favourable policy environment for maternal health can improve the adoption of evidence-based interventions and increase the utilisation of maternal health services in low- and middle-income countries. [ Creanga et al., 2023] Policies that address the continuum of care (preconception to postpartum), social determinants, and gender equity show better outcomes. [Anyanwu, Paschal, Ayo-Farai, Okongwu, & Ifesinachi, 2024] Gujarat’s Chiranjeevi public–private program (incentivizing institutional births among poor women) showed no significant effect on institutional delivery or maternal outcomes.[ Mohanan, Bauhoff, La Forgia, Bhatia, & Banerjee, 2014] Odisha’s cash-transfer Mamata scheme increased ANC uptake and immunization (e.g. 51% higher odds of ≥4 ANC and 1.7× odds of full child immunization) [Chakrabarti, Pan, & Singh, 2021] Kerala’s near-universal institutional delivery (~99.8%) is linked to high female literacy and strong public services.
Rwanda’s nationwide community health worker network and health insurance produced an MMR fall from 750 to 210 in a decade. [28] Nepal’s Female Community Health Volunteer (FCHV) program (52,000 local volunteers) is credited with promoting antenatal care and births, contributing to an 80% MMR reduction. [Binagwaho, Scott, Mukiibi, et al., 2018] LaQshya (Labour Room Quality Improvement Initiative) is a GOI program to upgrade delivery wards; evidence is emerging that focusing on quality (rather than only access) is key. Mamata in Odisha and similar maternity benefit schemes improve ante and postnatal care utilization, indirectly encouraging facility delivery. Mamata’s cash incentives led to significant increases in antenatal registration, counselling, and institutional deliveries. [Chakrabarti, Pan, & Singh, 2021]

METHODOLOGY

Research Design

A mixed-methods descriptive design was employed to examine trends in key maternal and child health (MCH) indicators and to explore the perspectives of frontline workers, and to identify gaps. Mixed-methods approaches provide a more complete understanding than quantitative or qualitative methods alone. The quantitative component involved secondary data trend analysis, while the qualitative component consisted of semi-structured interviews with health workers.

Research Questions

• Research Question 1: How have Meghalaya’s maternal mortality ratio (MMR), infant mortality ratio (IMR), institutional delivery rate, child immunization coverage, antenatal care (ANC) visits, and first-trimester registration changed from baseline to 2021 and 2024?
• Research Question 2: What trends are observed in each indicator over this period?
• Research Question 3: What insights do frontline health workers offer about these changes and ongoing challenges?

Data Collection and Sources

Baseline values for each indicator were obtained from published National Family Health Survey (NFHS) reports. NFHS provides comprehensive state-level estimates on health and nutrition, enabling comparisons over time. We used the most recent NFHS round available prior to 2021 as the baseline reference for Meghalaya (e.g. NFHS-4 or NFHS-5)

Baseline Data

Baseline values for each indicator were obtained from published National Family Health Survey (NFHS) reports. NFHS provides comprehensive state-level estimates on health and nutrition, enabling comparisons over time. The most recent NFHS round available prior to 2021 was used as the baseline reference for Meghalaya (NFHS-4 and NFHS-5).

Follow-up data

Data for the years 2021 and 2024 were extracted from the Meghalaya government’s health dashboard (MegHealth), a public real-time portal that aggregates program data across the state. MegHealth compiles MCH program data (e.g. from the “MOTHER” initiative) into one integrated source. The portal provides up-to-date indicators and analysis tools for monitoring health outcomes. The published values of MMR, IMR, institutional delivery rates, full immunization coverage, ANC coverage, and first-trimester registration for 2021 and 2024 were recorded directly from the MegHealth site. Where needed, units and definitions were matched to ensure comparability with NFHS data.

Participants and Sampling (Qualitative)

Frontline health workers at selected facilities were interviewed in March 2024. We conducted ten semi-structured interviews with personnel involved in maternal and child health service delivery (e.g. auxiliary nurse midwives, nurses, or health assistants) at the facilities where the quantitative assessment was done. Participants were purposively sampled to include “information-rich” cases – that is, workers with direct experience in the relevant services. This ensured that interviewees could speak knowledgeably about MCH program implementation and trends. Participants were recruited on-site at each facility. All interviews took place in a private area of the health centre (or via appointment at the facility) during March 2024. Before each interview, the researcher explained the study purpose and obtained informed consent. Participation was voluntary and confidentiality of responses was assured.

Qualitative Data Collection

Interviews followed a semi-structured format. The interview was prepared with open-ended questions about changes in health services, observed challenges, and perceived causes of trends. Probing follow-up questions were used as needed to explore participants’ responses in depth. Each interview lasted roughly 30–45 minutes. No audio recording was made; instead, the interviewer took detailed handwritten notes throughout each session. Taking notes during the interview helped ensure that all key questions were covered and served as a backup record of the conversation. After the interview, notes were reviewed and expanded as soon as possible to produce complete textual summaries of each participant’s responses.

Quantitative (Trend) Analysis

The 2021 and 2024 data from MegHealth were compared with the NFHS baseline and the NHM data for Meghalaya to assess changes over time. For each indicator, values were tabulated for baseline, 2021, and 2024. Simple descriptive analysis was used: we calculated absolute and relative changes (e.g. percentage change) between time points to identify trends. Results were presented in tables and charts highlighting increases or decreases in MMR, IMR, delivery rates, immunization coverage, ANC, and registration. This approach follows standard practices for health trend analysis using surveillance data.

Qualitative (Interview) Analysis

Interview notes were analyzed manually using a thematic coding approach. First, the researcher read through all interview summaries to become familiar with the data. Next, meaningful statements and observations were coded by hand. Codes were then grouped into broader categories (themes) that reflected common patterns across interviews (for example, “staffing challenges,” “community awareness,” or “data reporting issues”). Finally, themes were reviewed and refined to capture key facilitators or barriers reported by workers. Throughout this process, interpretations were grounded in the actual notes. No qualitative analysis software was used, given the small sample; instead, all coding and theme development were done manually to maintain close involvement with the data.

After separate analyses, the quantitative and qualitative findings were compared and integrated to provide a comprehensive view. Quantitative trends highlighted where performance improved or lagged, while interviews provided context for these changes (e.g., increased outreach efforts or resource constraints). This convergent mixed-methods strategy allowed triangulation of results, improving the robustness of conclusions.

Sources

Data sources include official NFHS reports and the Meghalaya MegHealth portal. The mixed-methods design and purposive sampling approach are supported by established research methodology literature. Interview methods follow guidance for semi-structured health research interviews, and note-taking was used as recommended when recording is not employed. All cited information comes from governmental and peer-reviewed sources as indicated.

RESULTS & FINDINGS

Quantitative Analysis

The data for various indicators are compared with the baseline. Changes are measured in terms of percentage and rate. 

Comparison of Maternal Mortality Rate (MMR) of Meghalaya

Table 1

*Baseline MMR is sourced directly from NHFS 4 (pre-policy). Live births for baseline are unavailable in the provided data.

MMR=Total Maternal DeathsTotal Live Births×100,000

Inferences

• MMR fell from 318 (2021) to 172 (2024), reflecting a 146-point reduction (-45.9%). This aligns with policy interventions like the MOTHER App (launched 2019) and CM-SMS (2022).
• Compared to the baseline MMR of 197 (pre-policy), 2024 shows progress despite the spike in 2021. (12.7% Improvement)
• MMR surged to 318 in 2021, likely due to pandemic disruptions or data reporting changes. Post-2021, policies drove rapid improvement.
• The 45.9% MMR reduction between 2021 and 2024 validates the impact of MOTHER Project and CM-SMS.
• Maintaining sub-200 MMR requires addressing persistent gaps (e.g., facility deaths, rural access).

Comparison of Infant Mortality Rate of Meghalaya

Table-2

*Baseline IMR is sourced from NFHS-4 (2015–16). Live births for baseline are unavailable in the provided data.

IMR=Total Infant DeathsTotal Live Birthsx1,000

Inferences

• IMR fell from 29.9 (2021) to 24.4 (2024), reflecting an improvement. (18.7% Decline) This aligns with policy interventions like expanded immunization coverage and improved neonatal care under the MOTHER Project.
• Compared to the baseline IMR of 30 (pre-policy), 2024 shows steady progress.
• IMR in 2021 (29.9) mirrored the baseline (30), likely due to pandemic disruptions or delayed policy impact. Post-2021, interventions accelerated progress.
• The 18.7% reduction between 2021 and 2024 validates initiatives like ANC tracking via the MOTHER App and community mobilization through VHCs.
•  Persistent infant deaths highlight the need to address neonatal care quality and postnatal follow-ups.

Comparison of Institutional Delivery Rate of Meghalaya

Table-3

Inferences

•  Institutional delivery rates increased by 16.4 percentage points (from 57.7% in 2021 to 74.1% in 2024).
• Reflects the success of interventions like the MOTHER App (tracking pregnancies) and CM-SMS (transit homes, transportation support).
• Compared to the pre-policy baseline of 54% institutional deliveries (NFHS-5), the 2024 rate shows a 20.1 percentage point improvement.
• Home deliveries reduced from 34,404 (42.3%) in 2021 to 22,132 (25.9%) in 2024—a 35.6% reduction.
• Total number of deliveries increased by 4,079 (5%), likely due to population growth or improved reporting.
• MOTHER App enables real-time tracking of pregnancies, ensuring timely referrals. By CM-SMS, transit homes and transport incentives reduced barriers for remote communities. Community mobilization improved health-seeking behaviour.
• Cultural preferences for home births and access challenges persist. This reflects for the 25.9% home deliveries that occurred.

Comparison of Immunization Coverage

Table-4

Coverage (%)=Fully Immunized InfantsTotal Live Births×100

Inferences

• It showed a 39.3% Improvement from baseline (61.4%) to 2024 (85.7%).
• Coverage reached 86.0% in 2021, likely due to focused immunization drives and MOTHER Project integration.
• Immunized infants grew by 5.2% (68,774 → 72,340) in 2024, but live births outpaced this growth (+5.6%).
• MOTHER App (launched 2019) and CM-SMS (2022) likely contributed to sustained high coverage by tracking pregnancies and linking them to immunization schedules.
• This reflects expanded routine immunization and the state’s investment in outreach (VHND days, ASHA mobilization).
• Nearly complete immunization is important for reducing infant deaths, as partly evidenced by the falling IMR.
• Notably, the interviews did not flag immunization as a problem area, implying these efforts have been largely successful.

Comparison of ANC Compliance

Table-5

Inferences

• ANC compliance surged by 20.5 percentage points (from 72.7% in 2021 to 93.2% in 2024). It showed a 28.2% Improvement.
• Compared to the pre-policy baseline of 57.1% ANC compliance (NHM, Meghalaya), the 2024 rate reflects an improvement with compliance reaching to 72.7% in 2021 and 93.2% in 2024.
• Interventions like the MOTHER App (tracking ANC visits) and CM-SMS (transport incentives for check-ups) drove this progress.
• Early policy adoption saw moderate gains (72.7%), likely due to initial MOTHER App rollout.
• Systematic interventions techniques (e.g., real-time ANC tracking, VHC mobilization) ensured 93.2% compliance, critical for reducing maternal and infant mortality.
• Mother App enabled real-time monitoring of ANC visits, ensuring timely follow-ups.
• CM-SMS scheme improved access to facilities for rural women.
• High ANC uptake is consistent with the reported use of primary care services: women may attend early but still drop out before delivery if disincentivized by home responsibilities.

Comparison of Rate of Timely Registration

Table-6

Inferences

• First-trimester registration increased from an estimated ~40% to 53.6% in 2021 and 56.9% in 2024 (a 42.3% rise from baseline).
• While this is progress, almost half of pregnancies are still registered late (after the first trimester).
• This shortfall aligns with qualitative findings (high fertility and workload) – women may delay even the first ANC if early pregnancy is unplanned or if family care is pressing.
• Continued education on early ANC, possibly through ASHAs and community leaders, could push this higher.

Qualitative Insights from Front-Line Workers

The interview sessions with the ANMs, Doctors and ASHA workers of various facilities in Meghalaya have revealed some measurable insights. A thematic decoding of the interviews was done, and key points have been highlighted.

Home deliveries and traditional practices

Frontline workers report that home births remain common in Meghalaya, often attended by traditional birth attendants (TBAs) whom the community deeply trusts. Despite government initiatives (e.g. transit homes, CMSMS) to promote facility births, many expectant mothers prefer home delivery for privacy, comfort, and the ability to tend to household duties and children.

Community Engagement & Access Challenges

Workers highlight persistent barriers in mobilizing communities. Cultural stigma and scepticism toward modern medical care (including mistrust of procedures) deter some families from seeking institutional care. Poor roads and difficult terrain further isolate villages. Workforce gaps exacerbate this: although Meghalaya reports one ASHA per village on average, some areas have reported unfilled posts or uneven ASHA presence.

Health system strengthening (MOTHER project, IPA) and remaining gaps

Staff praised the MHSSP’s efforts (including the “MOTHER” project) in improving public health facilities, especially those enrolled in Internal Performance Agreements (IPAs). IPAs are results-based contracts that tie funding to quality and performance. In pilot IPA facilities, rapid improvements were observed as hospitals invested in infrastructure, staff training and patient satisfaction. However, interviewees noted that not all facilities have IPA support. Non-IPA centers often lack basic amenities: record-keeping is weak, laboratory services are limited, and key MCH services (e.g. family planning outreach) are underdeveloped.

High fertility and maternal behaviour

Frontline providers emphasized Meghalaya’s relatively high fertility rates.  In practice, this means many women have closely spaced pregnancies and multiple young children at home. Interviewees observed that mothers often do not stay long in the hospital after a delivery – sometimes less than 12 hours – because they have no one to care for their other children.

Human resources and coordination issues

Providers reported high workloads. Medical officers and nurses are now expected to collect additional data and meet IPA targets, which some find burdensome given existing duties. Meanwhile, coordination between programs is weak. For example, the child health screening program (RBSK) collects data on schoolchildren, but this information often does not flow back to PHC staff, leading to information gap.

DISCUSSION

Insights from Quantitative Analysis

Figure- 1