Perspectives

Authors: Dr. K. Madan Gopal, Dr. Ties Boerma, and Dr. Usha Ram

In the past two decades, India has made remarkable strides in improving maternal and newborn health. Between 2000 and 2020, the country’s maternal mortality dropped from 327 to 97 deaths per 100,000 live births, while neonatal mortality fell from 44 to 20 deaths per 1,000 live births.  

These mortality reductions translate to approximately 60,000 maternal deaths averted from 2000 to 2019, and 628,000 neonatal deaths averted from 2000 to 2020.    

India’s average annual rate of change between 2000 and 2020 was 6.4% for maternal mortality ratio and 3.3% for neonatal mortality ratio, surpassing the average rates of decline globally for both indicators.  

The exceptional scale and speed of these reductions, given the sheer size and diversity of the country, make these gains all the more impressive and noteworthy. 

To find out what was driving this success, a study team supported by Exemplars in Global Health, including researchers from the National Health Systems Resource Center, the International Institute for Population Sciences, the India Health Action Trust, and the University of Manitoba systematically investigated a multitude of factors between 2020 and 2022 nationally and sub-nationally. The Ministry of Health and Family Welfare, Government of India, supported the study under the guidance of a steering committee and a technical working group. 

India’s exemplary progress on maternal and neonatal health is a story of success largely driven by expanding government health services. Various private-sector health services certainly remain popular in India, though popularity varies by state and type of service. However, the growing role of the public sector is evident in our analyses. For example, as institutional delivery increased from about 40% to 90% of all deliveries over the last two decades, the public sector grew to meet this demand. In 2019, 70% of deliveries occurred in public healthcare facilities.  

The increase in intervention coverage can be seen across the continuum of care, from the growing use of modern family planning methods to more women receiving care before, during, and after pregnancy.  

There have been substantial improvements in the access to and quality of antenatal care: 97% of women completed at least one antenatal care visit in 2018, up from 75% in 2000, and 85% of women in 2018 received high-quality antenatal care, up from 42% in 2000. Deliveries by c-section rose from 8% in 2000 to 24% in 2019. Postnatal care check-ups for the mother or newborn within the first two days of birth increased more than six-fold from 13% of births during 1998-99 to 83% during 2019-21. 

The study identified strong national policies and reforms, especially since 2005, that have directly and indirectly boosted coverage and quality of maternal and neonatal health services for all, while reducing inequalities between socio-economic groups to allow more of the population to access and benefit from these services. Our research identified six interrelated levers that drove India's maternal and neonatal health improvements:

1. Shifting to a broader range of healthcare programming, well beyond family planning, with a pro-poor focus 
2. Increased community engagement and outreach-based primary health care within communities to create demand for critical health services 
3. Shifting childbirth from homes and traditional birth attendants to health facilities and skilled birth attendants  
4. Improved availability of healthcare facilities and health worker services 
5. Increased access to evidence-based life-saving technical services 
6. Improved quality of maternal and newborn healthcare services 

These levers were underpinned by system-wide changes that decentralized health planning and management, increased the use of data systems for decision-making, and increased financial flexibility.  

India’s trajectory of strong maternal and neonatal mortality improvements began with the Child Survival and Safe Motherhood program, which ran from 1992 to 1997. The program broadened the health system’s focus beyond family planning. The Reproductive and Child Health I program followed from 1997 to 2005, emphasizing neonatal care and major efforts to train and equip traditional birth attendants.  

Between 2005 and 2012, when India launched the National Rural Health Mission under the Reproductive and Child Health II program, the country saw a stronger push to shift maternal, childbirth and neonatal care out of homes and into facilities through two flagship initiatives: the Accredited Social Health Activist community health worker program and the Janani Suraksha Yojana conditional cash transfer program.   

The Accredited Social Health Activist program aimed to provide every village in the country with a trained community health worker, greatly increasing women's awareness of and access to maternal and neonatal health services. From its launch in 2006 to 2020, contact with a frontline health worker during the third trimester rose from 34% to approximately 70%.  The Janani Suraksha Yojana scheme, launched in 2005, offered pregnant women a conditional cash transfer if they gave birth in a public facility or accredited private facility. This program increased institutional delivery rates, particularly among more disadvantaged regions and socioeconomic groups. 

At health facilities, the National Rural Health Mission under the Reproductive and Child Health II program also invested in 21-day skilled birth attendant training for auxiliary nurse midwives, among other providers. It also upgraded community health centers and increased staffing at primary health centers to ensure that 50% of primary health centers could function as 24/7 delivery points. 

In 2012, the National Health Mission and the Reproductive, Maternal, Neonatal, Child and Adolescent Health launched, ushering in the fastest period of decline for both maternal and neonatal mortality in the country. The initiatives during this period acknowledged the benefits of providing services across the continuum of care focusing on quality of care, from the neonatal to the maternal health life stages.  

India launched the National Quality Assurance Standards in 2013. In 2015, the government launched Dakshata, providing rapid clinical skills training across government facilities to improve expertise in maternal and neonatal health. Then, in 2017, the government’s LaQshya initiative rolled out labor room quality improvements. This period also saw the Janani Shishu Suraksha Karyakaram scheme, which was introduced to cover free maternal care, including c-sections, starting in 2011, and extended in 2014 to cover antenatal care and post-natal care for children up to 1 year of age.  

With each subsequent national program, the government has aimed to expand access to care and improve the quality of public healthcare by opening more facilities, extending operating hours, and growing India's pool of well-trained public sector health workers. These government initiatives and strategies expanded access to public sector health care and reduced the financial burden on families. 

One tool that helps put India’s success in the global context is the Integrated Maternal, Neonatal, and Stillbirth Mortality Transition Model, developed by the Exemplars research team. The tool helps understand national and state level progress in maternal and neonatal health as well as identify learning opportunities to continue progression. The transition model categorizes countries or regions into five phases based on levels of maternal and neonatal mortality, as well as stillbirth rates, with Phase I representing the highest mortality and Phase V representing the lowest mortality. Nationally, India progressed from phase II in 2000 to phase III in 2020, though there is substantial variation present at the state level. 

As countries progress along the transition and experience shifts from phases of higher to lower mortality, there are key characteristics associated with progress between the phases. Fertility declines are typically observed in phases I and II, and declines are typically related to improved women’s empowerment, education, and contraception access. Increased access to health services is typically observed in phases II and III as facility access increases and health workforce capacity grows. Cause of death shifts typically occur in phases II to IV as infections decline and indirect causes of death increase. Countries in the latest phases, IV and V, typically undergo improvements in quality of care as well as heightened efforts to reduce inequalities.  

The mortality transition model enabled the benchmarking of India’s impressive progress against trajectories seen in other countries, as well as comparing different transition phases of states within India. This work can also inform pathways to further mortality reduction in India, such as continuing to improve quality of service and targeting equity gaps.  

Despite India’s tremendous progress, disparities in health care access remain, especially between wealth groups and geographic areas. About 24% of the country's poorest quintile still give birth outside of health facilities, while institutional delivery is near universal among the highest wealth quintile. C-section rates also paint an unequal picture, at 7.3% among the poorest quintile and 39.1% among the highest wealth quintile in 2020. Surveys show that declines in neonatal mortality rate have been slower in rural areas, where almost three-quarters of all births occur, compared to urban areas, over the past two decades.   

Our research shows many opportunities to innovate and collaborate to move states and the whole country forward, mitigate geographic and other equity gaps, and accelerate the declines in states with higher mortality levels.   

Broad steps that India can take to bring its successes in maternal and neonatal health to all of the country’s mothers and babies, based on this research, include the following: 

1. Continue strengthening the public health system for maternal and neonatal health service provision. The government must maintain the momentum it has gained, which requires continuing to see and position itself as the primary provider of maternal and neonatal health care, further expanding coverage of maternal and neonatal health services while reducing the financial burden on families. 
2. Track and improve the quality of maternal and neonatal health. Addressing the indirect and health status-related causes of maternal and neonatal mortality, and improving the contents and quality of care that is being accessed. 
3. Intensify efforts to reach more disadvantaged socio-economic groups and regions. As inequalities in coverage of life-saving maternal and neonatal healthcare are reduced, special efforts are required to leave no one behind. This requires, among other things, universal and specifically designed policies to increase uptake among disadvantaged populations (e.g., no means testing, no barrier to entry), bringing all deliveries into well-equipped health facilities, and improving access to medically indicated c-sections. 
4. Foster a future learning agenda focused on successful strategies to address equity. This requires strong data collection and analysis to understand health system performance, particularly around human resources, facility capacity, and quality of care provided, equity analyses on access to and quality of services across the continuum of care, and an in-depth understanding of pathways for success at the district, block, and village levels to identify transferable solutions. 

Our full report is available here for more information about the drivers of India’s remarkable improvements in maternal and neonatal health.  

About the authors, Dr K Madan Gopal, Dr Ties Boerma, and Dr Usha Ram, are advisors and research partners with Exemplars in Global Health. In addition, Dr K. Madan Gopal is an advisor to the National Health Systems Resource Centre, a technical support institute with the National Health Mission. Dr. Ties Boerma is a professor of community health sciences at the University of Manitoba. He is also Canada Research Chair for Population and Global Health at the Centre for Global Public Health and director of the Countdown to 2030 for reproductive, maternal, newborn, child and adolescent health. Dr Usha Ram is a professor in Bio-Statistics & Epidemiology at the International Institute for Population Sciences, Mumbai. 

When Mumtaz Mahal died on June 17, 1631, while giving birth to her 14^th child, there was little remarkable about her story. At the time, women often gave birth to a dozen or more children and for every 100 to 200 births at least one mother died.

Nearly 400 years later, the risk of childbirth has declined significantly – but unevenly. The World Health Organization estimates that nearly 300,000 women die each year due to largely preventable complications related to pregnancy, childbirth, or during the postnatal period – the overwhelming majority of them in low- and middle- income countries. It is estimated that the probability that a 15-year-old girl will eventually die from a maternal cause is about 1 in 5,300 in high-income countries. But the risk is much higher – 1 in 49 – in low-income countries.

The single most important factor for preventing maternal mortality and ensuring safe childbirth is ensuring that skilled health personnel are present at every birth, which will accelerate progress toward not only reducing maternal and neonatal mortality and morbidity but also toward achieving Sustainable Development Goal 3 (SDG 3).

A skilled health professional can administer interventions to prevent and manage life-threatening complications, such as heavy bleeding, prevent infections, and make referrals to a higher level of care when needed.

SDG indicator 3.1.2 notes that the proportion of births attended by skilled health personnel is an indicator of health care utilization. It is a measure of the health system’s functioning and potential to provide adequate coverage for childbirth.

Currently the data on this indicator is mainly collected in population-based surveys. Women are asked “Who assisted with the delivery of (Name)?”. To answer this question the woman needs to provide the title of the health care provider who assisted her during the delivery.

However, that question alone is often not enough. Will the woman know or remember who supported with the birth of her child? Does she even have that information? Was the person who helped at the health facility a community health worker, a nurse, a midwife, a doctor, or an assistant midwife? There are a dizzying number of titles for individuals that provide childbirth assistance in health facilities around the world. A scoping review identified 108 different professional titles in low-and middle-income countries.

Moreover, this indicator does not provide insight into the availability or accessibility of services. Neither does it capture the quality of care received. The evidence also suggests that while countries reported relatively high levels of birth attendance by skilled health personnel, maternal and neonatal mortality rates have not proportionately decreased.

This enigma – the increasing percentage of births attended by a skilled birth attendant accompanied by stubbornly high rates of maternal mortality – has prompted researchers and health leaders around the world to better define and understand the indicator.

First, in 2018, an interagency group including WHO, UNICEF and UNFPA, the International Confederation of Midwives, the International Council of Nurses, the International Federation of Gynecology and Obstetrics, and International Pediatric Association updated and refined the definition of the widely used term and indicator “skilled birth attendant” (SBA).

The 2018 definition and associated statement outlined three critical competencies: that the individual health care provider is educated, trained, and regulated to national and international standards to be capable of:

1. Providing and promoting evidence-based, human-rights-based, high quality, socio-culturally sensitive and dignified care to women and newborns
2. Facilitating physiological processes during labor and delivery to ensure a clean and positive childbirth experience
3. Identifying and managing or referring women and/or newborns with complications

The definition also makes clear that skilled health personnel need to be working in an enabling environment. However well qualified, if skilled health personnel are overwhelmed by too many patients, have no drugs, equipment, electricity or water, then they cannot provide quality care. The definition also states that skilled health personnel need to work as part of a team and can refer patients to higher level services as needed.

The next phase of this effort is to operationalize this definition and use Nepal, Senegal, and Zambia as case studies. The goal of this work is to develop a feasible and useful measurement of skilled health personnel based on the revised definition.

The study is being conducted as part of the Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR) work portfolio and supported by research partners in Nepal, Senegal and Zambia in collaboration with UNICEF, UNFPA, the Global Financing Facility and Exemplars in Global Health. Nepal, Senegal and Zambia were selected as case study countries as these countries have been Exemplars in reducing maternal mortality.

We know that countries are very interested in understanding the challenges related to the measurement of coverage of skilled health personnel. The outcome of this research is expected to support and enable countries to measure the coverage of birth attended by skilled health personnel in a more accurate and useful way to inform policy and programs.

Ann-Beth Moller is a Technical Officer in the Department of Sexual and Reproductive Health and Research at World Health Organization