DECLINE IN FERTILITY LEVELS

Generally most strongly associated with mortality reductions in earlier phases of the transition framework

Across Exemplar countries, a decline in fertility was identified as a strong driver of overall reductions in NMR and MMR. This trend was linked to particularly sharp declines in fertility among adolescents as the age at first marriage generally increased, and birth intervals between children widened. A variety of factors such as increased school enrollment and delayed marriage contributed to this shift, in addition to improved access to contraception. Exemplar countries scaled up approaches to make family planning options more available by domestically producing pharmaceuticals, expanding community health worker networks, revamping supply chains, and prioritizing awareness campaigns. This was complemented by parallel efforts to strengthen women’s empowerment, with several Exemplar countries developing incentive programs for young girls to stay in school.

Country Spotlight: Bangladesh

Transitioned from phase X to phase Y between 2000 and 2020

In 1994, Bangladesh launched the Female Secondary School Stipend and Assistance Program (FSSAP), which aimed to increase the number of years that girls stayed in school. FSSAP introduced a uniform stipend and tuition subsidy for girls attending secondary school in rural areas, provided that they attended 75% of school days, maintained test scores, and remained unmarried until school completion.¹ This program supported over two million girls annually, and has been linked to delayed marriages and increased contraceptive use—two factors that have contributed to fertility declines in Bangladesh. Our analysis found that fertility declines in Bangladesh explained 44% of the MMR reduction and 47% of the NMR reduction between 2000 and 2019. Increased education among girls and women is one upstream driver contributing to this finding.

More information on how Bangladesh implemented these initiatives is available here:

• How did Bangladesh implement?

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IMPROVED ACCESS TO MATERNAL AND NEWBORN HEALTH CARE

Generally most strongly associated with mortality reductions in early/intermediate phases of the transition framework

Exemplar countries used diverse strategies to increase access and uptake of maternal health services. For example, many Exemplar countries removed user fees for delivery services in health facilities. In addition, several Exemplar countries implemented conditional cash transfer programs for eligible women who accessed antenatal care and facility-based delivery services. Beyond financial barriers, Exemplar countries also implemented innovative approaches to mitigate logistical and physical barriers to accessing care. One such approach was maternity waiting homes, which provided a safe place for pregnant women to stay before delivery—often meant for women in rural areas far from health facilities. Emergency transportation services were also commonly expanded in Exemplar countries, with a focus on timely referrals to higher-level facilities equipped for specialized delivery care, especially in case of complications.

Country Spotlight: Ethiopia

Transitioned from phase X to phase Y between 2000 and 2020

As Ethiopia transitioned to phases of lower mortality, the country made key strategic decisions to prioritize and expand access to health services, particularly in rural areas. A key focus of Ethiopia’s Health Extension Program (HEP) is ensuring access to primary health care services—especially maternal and newborn care.² HEP began in the four larger agrarian regions, later expanding to pastoralist communities, then to urban centers. To further reduce barriers to care, Ethiopia enacted a national plan in 2012 to distribute a four-wheeled ambulance to every rural district.³ By 2019, maternity waiting homes were also scaled up to over half of facilities, offering a safe place for pregnant women to stay before delivery.⁴

More information on how Ethiopia expanded access to care is available here:

• How did Ethiopia implement?

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PRIORITIZING QUALITY OF MATERNAL AND NEWBORN HEALTH CARE

Generally most strongly associated with mortality reductions in intermediate/later phases of the transition framework

As coverage levels increased, Exemplar countries also improved the quality of maternal and newborn health care. Several countries introduced health facility standards that helped establish norms for the types of equipment, pharmaceuticals, and personnel that should be available in specific types of facilities. This led to more standardized service delivery—for example, ensuring that all primary-level facilities were equipped with basic delivery kits, essential medicines, and skilled birth attendants, alongside strengthening referral systems to higher-level facilities. In several Exemplar countries, these improvements were accompanied by a shift from lower-level health facilities to hospitals as the most common place of delivery. Health workforces continued to grow in size and skill in order to provide this high-quality care, with many Exemplar countries offering courses or training programs to enhance providers’ skills in key areas of maternal and newborn care.

Country Spotlight: India

Transitioned from phase X to phase Y between 2000 and 2020

The establishment of the Indian Public Health Standards helped set quality standards for various types of facilities across the states of India, including specifications for equipment and medical products.⁵ These standards were later accompanied by the 2017 Labor Room Quality Assurance Initiative (LaQshya), which emphasized the importance of patient-centered maternity care in its quality standards.⁶ These reforms were complemented by efforts to strengthen referral systems and enhance the health workforce through training, capacity strengthening, and task shifting. Collectively, these efforts marked a shift from a primary focus on service coverage to an emphasis on quality.

More information on how India prioritized quality of care is available here:

• How did India implement?

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INCREASED EQUITY IN MATERNAL AND NEWBORN CARE

Generally most strongly associated with mortality reductions in later phases of the transition framework

Many initiatives in Exemplar countries were intentionally designed with a pro-poor, pro-rural focus intended to reach the most vulnerable communities. Policies that removed user fees or included conditional cash transfers were often first implemented in the most marginalized communities and regions before being scaled up. These policies helped increase coverage of maternal and newborn health services among poor and rural communities, with rising Cesarean section rates among the poorest serving as an indicator of improved access to comprehensive services. Exemplar countries also instituted several measures intended to expand lower-level facility networks in rural areas, reducing travel time to health facilities for isolated communities and in some regions, strengthening referral systems to higher-level facilities. Some Exemplar countries introduced measures to promote a more equitable distribution of the health workforce, including incentives or mandatory placements in remote areas.

Country Spotlight: Morocco

Transitioned from phase X to phase Y between 2000 and 2020

To promote equitable access to care, Morocco introduced a policy in 2008 that removed that eliminated user fees for obstetric services in public facilities, including delivery and Cesarean sections, regardless of economic status.⁷ A subsequent policy in 2012 eliminated user fees for treatment of complications, referral costs, and newborn care.⁸ The government introduced reimbursement to public facilities based on the expected volume and type of services to help mitigate financial barriers to facility-based care for women. These policies were implemented alongside the Rural Obstetrical Emergency Medical Service program, also launched in 2008, which provides free ambulances for rural areas and prioritizes women with high-risk pregnancies.⁷ Together, these initiatives have contributed to improved access and outcomes for poorer, rural communities in Morocco.

More information on how Morocco enacted policies to remove barriers to maternal and newborn care is available here:

• How did Morocco implement?

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SHIFT FROM DIRECT TO INDIRECT CAUSES OF DEATH

Typically occurs steadily along a country’s progression from phase 1 to phase 4

As countries progress from earlier to later phases of the transition framework, the specific causes of maternal and neonatal death tend to shift from direct, often infectious causes to more indirect causes related to underlying health conditions. For example, the transition framework analysis found that from phases 1 to 4, the median percentage of neonatal mortality attributable to infections declined from 27.9% to 7.3%.⁹ Because direct causes of maternal and neonatal mortality are generally more responsive to existing interventions and protocols, this decline is strongly associated with increased health care utilization, especially institutional delivery.

Country Spotlight: Niger

Transitioned from phase X to phase Y between 2000 and 2020

In recent years, Niger has made rapid progress in addressing postpartum hemorrhage, a leading cause of maternal mortality. The country scaled up nationally a low-cost, three-step protocol that contributed to a 53% reduction in postpartum hemorrhage-related deaths during its implementation.¹⁰ As a result, the percentage of maternal deaths due to postpartum hemorrhage declined from 32% in 2013 to a constant level of about 10% between 2015 and 2020.¹⁰ Addressing direct causes of death like postpartum hemorrhage with known, effective protocols and treatments has helped contribute to progress in reduction of maternal mortality.

More information on how Niger implemented its nationwide strategy to reduce postpartum hemorrhage is available here:

• How did Niger implemented

Country Spotlight: India (Maharashtra, Tamil Nadu)

Transitioned from phase X to phase Y between 2000 and 2020

Exemplar states in India from the lower mortality cluster, Maharashtra and Tamil Nadu, improved access to high quality health care, contributing towards the shift from direct to indirect causes of death. Both states strengthened health infrastructure to expand access to advanced care, including upgrading lower-level facilities and developing dedicated newborn care units—improving access to medical interventions that address preventable mortality. Examples of initiatives that helped to improve facility readiness and reduce mortality from direct causes include Tamil Nadu’s maternal death surveillance and response system by informing decisions such as revised blood bank placement; as well as Maharashtra’s LaQshya-Manyata private facility quality improvement program by improving healthcare worker training. Both states have seen substantial decreases in neonatal causes of death such as prematurity/low birth weight, asphyxia, and infections.

More information on how Maharashtra and Tamil Nadu implemented these initiatives is available here:

• How did lower mortality states implement?