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Delayed childbearing and advanced maternal age are now common trends. India must adapt its maternal healthcare priorities to reflect this shift.
Image Source: Getty
This essay is part of the series: World Health Day 2025: Healthy Beginnings, Hopeful Futures
The trend of delayed childbearing and advanced maternal age (AMA) has become more prominent globally, with India following a similar trajectory. This shift represents progress in terms of women’s autonomy and prevents health hazards associated with early pregnancy and inadequate spacing between pregnancies. However, delaying having children is associated with several risks as growing evidence indicates that advanced maternal age is linked to an increased likelihood of both maternal and neonatal health complications. While India has made progress in reducing maternal and perinatal mortality rates, these figures continue to remain high.
As India strives to achieve its Sustainable Development Goal (SDG) target of reducing maternal mortality to below 70 deaths per 100,000 live births by 2030, the impact of delayed childbearing must not be overlooked in maternal health policies.
The chances of ectopic pregnancy, preeclampsia, placental complications and developing chronic conditions such as hypertension, diabetes, and cardiovascular diseases increase as well, associated with a higher risk of death during childbirth.
Fertility declines with increasing maternal age, particularly after the age of 35. According to the American College of Obstetricians and Gynaecologists, AMA is thus traditionally defined as pregnancy occurring in women aged 35 or older. Women over 35 have a higher pregnancy risk and are more likely to require C-sections. The chances of ectopic pregnancy, preeclampsia, placental complications and developing chronic conditions such as hypertension, diabetes, and cardiovascular diseases increase as well, associated with a higher risk of death during childbirth. In India, 17 percent of women give birth after 35 years. India accounts for nearly 12 percent of global maternal deaths, which amounts to an estimated 1.3 million maternal deaths in the past two decades, with the majority stemming from direct medical causes that increase with age.
Additionally, high-risk pregnancies (HRP) contribute to 75 percent of perinatal deaths in the country. According to research, pregnancies in older age are associated with risks of chromosomal abnormalities such as Down syndrome, structural defects, particularly heart defects, limb malformations, and abnormalities in the urinary or digestive systems. With age, the chances of miscarriage also rise, with women over 40 2.4 times more likely to experience miscarriage than those under 35. Babies born to older mothers are at a higher risk of being premature or having a low birth weight, leading to potential development challenges.
Data Source: NFHS-3 (2005-06), NFHS-4 (15-49), NFHS-5 (2019-21)
As indicated in Figure 1, while non-live births in India have declined over the years for mothers aged 15-19, they have increased for women over the age of 35. Table 1 shows the significantly higher rates for childhood mortality among women aged 40-49, approximately double the childhood mortality rates among mothers aged 20-29. This disproportionately high burden among older mothers highlights the importance of policy intervention to adequately support them in a world of changing reproductive trends.
Table 1: Early Childhood Mortality Rates by Mother’s Age at Birth, NFHS-5 (2019-21)
| Mother’s Age at Birth | Neonatal Mortality | Postneonatal Mortality | Infant Mortality | Child Mortality | Under-five Mortality |
| <20 | 33.7 | 11.6 | 45.3 | 7.6 | 52.5 |
| 20-29 | 23.0 | 10.1 | 33.1 | 6.2 | 39.2 |
| 30-39 | 26.3 | 9.8 | 36.1 | 8.9 | 44.7 |
| 40-49 | 38.4 | 12.4 | 50.8 | 25.4 | 74.9 |
Data Source: NFHS-5 (2019-21)
Indian public health policy primarily focuses on age at first childbirth, overlooking the age at subsequent birth which also significantly determines maternal and child health outcomes. As childbearing shifts to later ages, the risks accumulate over successive pregnancies. Nevertheless, a World Health Organisation (WHO) study finds that when managed by modern obstetric methods and delivered in modern healthcare centres, older women can have good pregnancy outcomes, highlighting the need for a shift in focus in maternal health policies to build a system that can accommodate the changing reproductive landscape. In an ageing reproductive cycle, targeted interventions in antenatal care (ANC), risk screening—particularly, second-trimester anomaly scans, routine foetal aneuploidy testing, and specialised maternal support for older expectant mothers are important to mitigate these risks.
A meta-analysis indicates that women who postponed childbearing were often unaware of the associated risks of delayed childbirth. India’s public health information and education communication programs predominantly focus on early pregnancy risks, with inadequate counselling on the impact of delayed pregnancy. By implementing programmes for raising community awareness, integrating fertility education into family planning services, and training healthcare workers to communicate risks effectively, women can make better decisions.
A World Health Organisation (WHO) study finds that when managed by modern obstetric methods and delivered in modern healthcare centres, older women can have good pregnancy outcomes, highlighting the need for a shift in focus in maternal health policies to build a system that can accommodate the changing reproductive landscape.
While several government programmes such as the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Labour Room Quality Improvement Initiative (LaQshya), Surakshit Matritva Aashwasan (SUMAN), Live Saving Anaesthesia Skills (LSAS), Emergency Medical Obstetric Care (EMOC), etc,. address HRPs, they focus primarily on strengthening basic emergency obstetric and neonatal care and comprehensive emergency obstetric and newborn care services, with limited attention given to primary and secondary care facilities.
According to NFHS-5, as evident in Figure 2, there are significant variations across urban and rural regions in infant mortality from delayed pregnancies. This variation shows the impact of limited healthcare access, poor maternal nutrition, and lack of specialised ANC for HRPs in rural areas. While urban women have access to private facilities and assisted reproductive technologies, rural women struggle with delayed HRP detection, inadequate emergency obstetric care, and gaps in HRP tracking and ANC utilisation. Addressing these disparities requires a streamlined referral system, expanding telemedicine access, and training rural healthcare providers to manage HRPs associated with advanced maternal age.
Data Source: NFHS-5 (2019-21)
Additionally, there is significant variation across states, with some states such as Kerala, Maharashtra, Telangana, Andhra Pradesh, Tamil Nadu, Gujarat, and Karnataka already having achieved the SDG targets, whereas others including Northeastern states are still struggling to combat maternal and perinatal deaths. Innovative initiatives such as the ARMMAN initiative by the Governments of Telangana and Andhra Pradesh provide a six-month-long phased training to Auxiliary Nurse Midwives (ANMs), Medical Officers (MOs), and specialist doctors, using algorithmic colour-coded protocols for end-to-end management of HRPs for all levels of primary care-should be scaled. The programme helped over 56 million pregnant women, new mothers, and their families and trained over 4.8 lakh health workers across regions in India. By actively designing innovative programmes and monitoring their impact, better health outcomes can be achieved.
The programme helped over 56 million pregnant women, new mothers, and their families and trained over 4.8 lakh health workers across regions in India.
Barriers to healthy reproduction, including workplace policies, should be reviewed. Research indicates that career aspirations and financial security contribute to women’s decisions to delay pregnancies, and policies should be designed to help women support their career aspirations and motherhood. Accounting for the needs of older women in maternity leave policies-including more frequent medical supervision, longer recovery periods and supportive work arrangements and child care options-is important as well. According to research, in low and middle-income countries, each additional month of paid maternal leave is associated with a 13 percent relative reduction in infant mortality. Currently, the Maternity Benefit (Amendment) Act of 2017 in India mandates 26 weeks of paid maternity leave, and the Social Security Code, of 2020 mandates all organisations with over 50 employees to have crèche facilities, along with coverage for unorganised and contract-based workers, however, on-ground implementation remains low. By addressing gaps in implementation and making additional accommodations, a system that truly empowers women can be built.
While delaying the birth of the first child is important, the median age at subsequent childbirths is also vital to the overall health and survival of women and children. India has come a long way in improving the outcomes of the former, but the latter remains overlooked in the child and maternal health policy discourse. India must redefine its maternal healthcare priorities to be better tailored to an evolving reproductive landscape. Additional research and targeted interventions can help mitigate the risks faced by mothers aged over 35, reducing the likelihood of high-risk pregnancies, and further empowering them to balance their aspirations with motherhood. Delayed childbearing and advanced maternal age are no longer the exceptions but the reality of modern reproductive trends, calling for a system that is prepared to provide adequate support for all mothers and children.
Nimisha Chadha is a Research Assistant at the Observer Research Foundation
The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.
Nimisha Chadha is a Research Assistant with ORF’s Centre for New Economic Diplomacy. She was previously an Associate at PATH (2023) and has a MSc ...
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