Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

Abstract

Introduction: India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions.

Methods: The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews.

Results: India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor.

Conclusion: Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

Keywords: Child health; Health policy; Health services research; Health systems; Maternal health.

Figure 1. Maternal mortality ratio per 100 000 live births and neonatal mortality rate per 1000 live births, with average annual rate of change (AARC, %) by policy period, India (SRS, 1992–2019). SRS, sample registration system.

Figure 2. National trends in coverage of antenatal care visits (any ANC), ANC with contents (ANCq) and institutional deliveries (ID, %), with average annual rate of change (AARC, %) by policy period, India (pooled NFHS and DLHS surveys, 1992–2018). DLHS, District Level Household Survey; NFHS, National Family Health Survey.

Figure 3. Institutional and C-section deliveries by household wealth tertile, India (NFHS, 1998–2021). NFHS, National Family Health Survey.

Figure 4. India’s national health policies and programmes related to maternal and newborn health. ANC, antenatal care; ANM, auxiliary nurse midwife; ASHA, accredited social health activist; CHC, community health centre; CSSM, Child Survival and Safe Motherhood; FRU, first referral unit; HBNC, home-based newborn care; JSSK, Janani Shishu Suraksha Karyakaram; JSY, Janani Suraksha Yojana; LaQshya, labour room quality improvement initiative; LSAS, life-saving anesthetic skill; MNH, maternal and neonatal health; MTP, medical termination of pregnancy; NSSK, Navjaat Shishu Suraksha Karyakram; PHC, primary health centre; PMMVY, Pradhan Mantri Matru Vandana Yojana; PMSMA, Pradhan Mantri Surakshit Matritva Abhiyan; POSHAN Abhiyaan, Prime Minister’s Overarching Scheme for Holistic Nutrition (intersectoral mission that includes a focus on early and exclusive breast feeding, nutritional supplementation for adolescent girls, pregnant women and lactating mothers); SBA, skilled birth attendant; SUMAN, Surakshi Matritva Aashwasan; TBA, traditional birth attendant; VHND, village health and nutrition day; VHSNC, village health, sanitation and nutrition committee.