A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India

Abstract

Background: India's progress in reducing maternal and newborn mortality since the 1990s has been exemplary across diverse contexts. This paper examines progress in two state clusters: higher mortality states (HMS) with lower per capita income and lower mortality states (LMS) with higher per capita income.

Methods: We characterised state clusters' progress in five characteristics of a mortality transition model (mortality levels, causes, health intervention coverage/equity, fertility and socioeconomic development) and examined health policy and systems changes. We conducted quantitative trend analyses, and qualitative document review, interviews and discussions with national and state experts.

Results: Both clusters reduced maternal and neonatal mortality by over two-thirds and half respectively during 2000-2018. Neonatal deaths declined in HMS most on days 3-27, and in LMS on days 0-2. From 2005 to 2018, HMS improved coverage of antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) by over three-fold. In LMS, ANCq, institutional delivery and PNC rose by 1.4-fold. C-sections among the poorest increased from 1.5% to 7.1% in HMS and 5.6% to 19.4% in LMS.Fewer high-risk births (to mothers <18 or 36+ years, birth interval <2 years, birth order 3+) contributed 15% and 6% to neonatal mortality decline in HMS and LMS, respectively. Socioeconomic development improved in both clusters between 2005 and 2021; HMS saw more rapid increases than LMS in women's literacy (1.5-fold), household electricity (by 2-fold), improved sanitation (3.2-fold) and telephone access (6-fold).India's National (Rural) Health Mission's financial and administrative flexibility allowed states to tailor health system reforms. HMS expanded public health resources and financial schemes, while LMS further improved care at hospitals and among the poorest.

Conclusion: Two state clusters in India progressed in different mortality transitions, with efforts to maximise coverage at increasingly advanced levels of healthcare, alongside socioeconomic improvements. The transition model characterises progress and guides further advances in maternal and newborn survival.

Keywords: Child health; Health policy; Health systems; Maternal health; Public Health.

Figure 1

Comparison of state-specific maternal mortality ratio (MMR) and neonatal mortality rate (NMR) levels in 2000 and 2018 by state per capita income (PCI) (SRS). West Bengal with a similar MMR and NMR as lower mortality state (LMS) yet lower per capita income in 2018 was included in the LMS cluster. Uttarakhand with a similar MMR and NMR to higher mortality state (HMS), but higher PCI in 2018 was included in the HMS cluster. In 2000, Uttarakhand was part of Uttar Pradesh, Telangana was part of Andhra Pradesh and Jharkhand was part of Chhattisgarh, but by 2018, they were all separate states.

Figure 2

Mortality transition in India’s lower and higher mortality state clusters (SRS, 2000–2018). The dots represent the mortality estimates published by SRS from 2000 to 2018. The solid lines connect the 2000 SRS estimates to the 2018 estimates for the two clusters separately.

Figure 3

Neonatal mortality rate (NMR) (3-year moving averages) and maternal mortality ratio (MMR) trends, and the average annual rates of change (AARC, %) in different policy periods, in lower and higher mortality state clusters (SRS, 1992–2018). CSSM, Child Survival and Safe Motherhood; NHM, National Health Mission; NRHM, National Rural Health Mission; RCH I, Reproductive and Child Health I; SRS, Sample Registration System.

Figure 4

Trends in any antenatal care (ANC), antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) within 48 hours of birth (%), with average annual rates of change (AARC, %) in different policy periods, in the two state clusters (NFHS and DLHS pooled data, 1992–2018). CSSM, Child Survival and Safe Motherhood; DLHS, District Level Household Survey; NFHS, National Family Health Survey; NHM, National Health Mission; NRHM, National Rural Health Mission; RMNCH+A, Reproductive, Maternal, Neonatal, Child and Adolescent Health.

Figure 5

Trends in coverage inequalities in the two state clusters between A) urban/rural residence and B) wealth tertiles using slope index of inequality (percentage points) (NFHS, 2005-6, 2019-21). DLHS, District Level Household Survey; NFHS, National Family Health Survey.

Figure 6

Trends in socioeconomic development indicators in the two state clusters (NFHS, 1992-3, 1998-99, 2005-06, 2015-16 & 2019-2021). HMS, higher mortality state; LMS, lower mortality state; NFHS, National Family Health Survey.