Table 1 Standard for maternal health in India: expected behavior, obligation, and responsibilities

Legal standards: The Indian Constitution, the National Health Bill of 2009, and national policies and programs have guaranteed maternal survival as fundamental human rights and the government’s obligation [40, 52]. Further, being a signatory of international human rights frameworks—for example, the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) (1979) and the International Conference on Population and Development (ICPD) (1994)—the Indian government is obliged to realize timely and non-discriminatory access to appropriate maternal health services, irrespective of all racial and economic background, and to adopt necessary policy, legislative, budgetary, and administrative measures to ensure those entitlements [41, 93, 94]. The legal provisions of the Indian government like the Right to Information (RTI) Act and the Public Interest Litigation (PIL) also guarantee fundamental rights, including health [19, 41, 52].

Policy standards: Maternal mortality reduction has been a commitment of the Indian government since 2005 through the launch of Reproductive and Child Health Program-II and the National Rural Health Mission (NRHM) [75]. It has specifically emphasized equity in maternal health through a fully functional and accountable health system that particularly reaches the rural and the socio-economically vulnerable groups. Further, it also entitles free maternal health care through initiatives like the Janani Suraksha Yojana (JSY) and the Janani Shishu Suraksha Karyakram [36]. Similarly, state-specific programs to aid women to use maternal health services, for example, Chiranjeevi Yojana [95] and Thayi Bhagya Yojana—public–private partnership schemes for poor women in Gujarat and Karnataka, respectively, also are the obligation of the states. Besides, the Indian government mandated maternal death reviews to reduce maternal deaths by addressing service-related factors at all levels of maternal health care [38].

Performance standards: The NRHM identifies community-based monitoring, surveys, and internal monitoring to ensure accountability of the health system against the standards or services guaranteed. It has also emphasized the involvement of Panchayati Raj Institutions—locally elected representatives; Accredited Social Health Activists (ASHA); Village Health; Sanitation and Nutrition Committee (VHSNC); and Rogi Kalyna Samiti—a primary health center-level committee, self-help groups, and community-based organizations in monitoring and accountability of the health system, besides planning [36]. The NRHM has also laid out standards in terms of goals, targets, strategies, plans, operational guidelines, tools (e.g., International Public Health Standards), citizen charters, etc. for maternal health at various levels of the Indian health system. Further, clinical and disease management guidelines developed by the health ministry, respective disease control and management centers, health professional bodies, and the World Health Organization also serve as standards for performance for health professionals (e.g., doctors, nurses).