Benchmarking progress in India

While lessons from Exemplar countries, including India, are designed to provide insights for peer countries, Exemplar countries themselves can also benefit from cross-country comparisons. Contextualizing India’s progress in a cross-country framework can provide insight into aspects of maternal and newborn health that India has particularly excelled in, while also identifying opportunities for further improvement.

Positioning India in the Integrated Maternal, Neonatal, and Stillbirth Mortality Transition Framework

Learnings from a multi-country analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework, is useful as India looks to further reduce neonatal and maternal mortality. In this framework, maternal and peri-neonatal (neonatal mortality including stillbirths) mortality are categorized into five phases, with phase I indicating higher mortality and phase V indicating lower mortality.¹ The transition framework is a tool that can be used to benchmark country progress and chart a path to progress—with distinct drivers mapped to successive steps.

Through this multi-country analysis, key factors were identified that were associated with progress through the transition, shown in Figure 22. Advancements beyond phase I were often linked to contraceptive use and fertility declines. Further progress through phases II and III often occurred as coverage of antenatal care, institutional delivery, skilled birth attendance, and postnatal care improved, in part due to an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in phase III, as preventable infections represented a shrinking portion of deaths, whereas indirect causes contributed a growing share of deaths. Finally, transitions to phases IV and V frequently reflected a prioritization of health equity, as vulnerable communities gained access to interventions previously only accessible to richer, more urban, or highly educated communities.¹

From 2000 to 2018, India advanced from early phase II to mid-phase III as shown in Figure 23. In line with factors associated with progress by phase, India has experienced a major fertility decline, seen widespread expansion of health infrastructure, improved key coverage indicators such as institutional delivery, and lessened the burden of direct causes of death such as infections.

During this same time period, the higher mortality state cluster progressed from phase I to early phase III, while the lower mortality state cluster advanced from mid-phase II to early phase IV as shown in Figure 23. While the lower mortality state cluster remains one phase ahead of the higher mortality state cluster, both have made substantial progress in fertility reduction, health service coverage, and mitigating the burden of direct causes of death.

Factors key for progressing in the mortality transition framework

This framework can also be leveraged to identify factors that may be key as India looks to continue reducing mortality, ultimately progressing to phase IV. These factors include improving equity in health service coverage, addressing deaths linked to indirect health factors, and expanding the country’s network of human resources for health. In this section, we assess India’s status on these factors compared to phase-specific ranges defined by the transition framework.

Equitable health service coverage

Family planning and fertility

One dimension of reproductive and maternal health where India has done well in achieving relatively equitable coverage is family planning. In the 1992–1993 NFHS, demand for family planning satisfied by modern methods was 70.3% among the wealthiest tertile and 52.8% among the poorest tertile—constituting a 17.5% point gap (Figure 24).² By the 2019–2021 NFHS, this gap had narrowed to 3.7% points as demand satisfied using modern methods improved to 81.2% among the poorest tertile and 84.9% among the wealthiest tertile.³ This trend is mirrored for demand satisfied among urban and rural populations. Whereas in the 1992–1993 NFHS, demand for family planning satisfied by modern methods was 7.5% points higher in urban communities², by the 2019–2021 NFHS it had declined to 0.1% points.³ These trends are mirrored in higher and lower mortality state clusters, with progress accelerating particularly sharply in the last decade.

These factors have contributed to a fertility decline—with data from India’s 2019–2021 NFHS showing fertility levels that are lower than ranges typical for phase III.³ Looking ahead, the country’s total fertility rate and adolescent fertility rate are both in the range typical for phase IV.

Antenatal care

In contrast to family planning, coverage of at least four antenatal care visits (ANC4+) constitutes an indicator with lingering equity gaps. While coverage is generally higher and more equitable in the lower mortality state cluster, nationally and in the higher mortality state cluster, wealthier and urban populations tend to have substantially higher ANC4+ coverage.

In the 1992–1993 NFHS, there was a 41.5% point difference in ANC4+ coverage between the wealthiest and poorest tertiles—with coverage levels respectively at 52.9% and 11.4%.² By the 2019–2021 NFHS, this gap had narrowed to 21.3% points as ANC4+ coverage improved to 71.2% among the poorest tertile and 45.9% among the wealthiest tertile (Figure 25).³ The gap in ANC4+ coverage between urban and rural populations also narrowed during this period from 27.2 to 14.4% points.^2,3

According to the integrated transition framework, typical ANC4+ coverage levels for a country in phase III range from 55.0% to 81.1%.¹ The national ANC4+ coverage level of 58.5% from India’s 2019–2021 NFHS is, therefore, at the low end of this range.³ Looking ahead, countries in phase IV typically have ANC4+ coverage levels ranging from 84.1% to 94.3%, meaning that ANC coverage may be a key priority as India seeks to continue its trajectory of progress.¹

Institutional delivery

Equitable coverage of institutional delivery has improved substantially in India in the last three decades. In the 1992–1993 NFHS, 56.2% of births among women in the wealthiest tertile occurred in a health facility, whereas only 7.7% of births among women in the poorest tertile took place in a health facility.² This gap of 48.6% points lingered, and slightly worsened, until the 2005–2006 NFHS when the institutional delivery coverage gap was 58.1% points between the wealthiest and poorest tertiles (Figure 26).⁴ In the decade that followed, that gap was halved as the 2015–2016 NFHS found it to be 29.0%.⁵ As of the 2019–2021 NFHS, the institutional delivery rates among the wealthiest and poorest tertiles were respectively 96.6% and 79.8%, constituting a substantially improved gap of 16.9% points.³ The urban/rural coverage gap for institutional delivery followed a highly similar trend, narrowing substantially in the decade between the 2005–2006 NFHS and 2015–2016 NFHS. The 2019–2021 NFHS found that the institutional delivery rate for urban communities was 93.8% and for rural communities was 86.7%, representing a 7.1% point gap.³ These equity gaps are generally wider across state clusters when specifically considering delivery in hospitals.

The integrated transition framework helps contextualize that narrowing gaps in institutional delivery mark one of the strongest successes in India over recent decades. While these gaps were wider in the 1990s, by the mid-2010s the gaps were narrower than typical for a country in phase III. Looking ahead, institutional delivery rates across wealth tertiles and urban/rural residence are on track with what is typically seen in phase IV.

Cesarean section

In contrast to other indicators highlighted throughout this section, C-section stands out as an indicator that has experienced widening gaps across wealth and urban/rural equity dimensions. This is linked to rising rates of C-section in recent years, especially among wealthier, urban populations who are more likely to access care at private facilities. Assessing C-section rates among the poorest communities can provide valuable insight into how accessible the intervention is to all populations, in cases that are more likely to be medically necessary.

At the time of the 1992–1993 NFHS, the C-section rate among the poorest wealth tertile was 0.5% compared with 5.9% among the wealthiest tertile.² By the 2019–2021 NFHS, these C-section rates had increased to 9.6% and 35.8 %, respectively (Figure 27).³

The integrated mortality transition framework helps contextualize C-section rates among the poorest. India’s C-section rate among the poorest is within the range of typical values for a phase III country, and looking ahead, it is also within the range of typical values for a phase IV country.

Although improved access to C-section is a key contributor to India’s progress in reducing neonatal and maternal mortality, targeting this intervention to mainly medically necessary cases may emerge as a priority for India in future years. The World Health Organization suggests that C-section rates higher than 10% to 15% are not associated with additional mortality reductions.⁶ Assessing C-section rates in a manner that disaggregates by wealth and urban/rural residence can help identify nuanced trends in access to this intervention that may be masked by overall C-section rates.

Deaths due to indirect health factors

As countries progress through the transition framework, the percentage of maternal and neonatal deaths due to direct causes such as infection typically decreases. This trend is generally complemented by an increase in the percentage of deaths linked to indirect health factors. For example, the transition framework analysis found that across countries, the median percentage of neonatal deaths due to infections decreased from 27.9% to 7.3% between phases I and V.¹

As highlighted earlier, the percentage of maternal and neonatal deaths in India due to infections has decreased, mirroring the general trend seen across countries. In turn, to continue reducing overall mortality, it becomes increasingly important to address deaths related to indirect causes of death. Risk factors such as maternal anemia, diabetes, and hypertension will be priorities that may require broader health sector integration as India seeks to continue reducing mortality and advance to the next phase of the transition framework.

Expanded health workforce and infrastructure

This narrative synthesis details several measures that India has taken to scale up and empower providers over the last two decades, which have contributed to the country’s decline in neonatal and maternal mortality. In recognizing these advancements, we also note that continued health workforce expansion and upskilling is likely to be a key priority as the country looks ahead to future phases of the transition framework. In particular, skilled human resources for health with the capacity to address complications will be important as deaths from more direct causes decline.

A 2017–2018 report from India’s National Sample Survey Office indicates that the country had 6.1 physicians and 10.6 nurse/midwives per 10,000 members of the population.⁷ These values represent increases from health workforce statistics in the early 2000s and are consistent with health workforce densities usually seen for a country in phase III. However, the transition framework highlights that health workforces in phase IV countries have substantially higher densities. The median density for physicians is 10.2 per 10,000 people, and 18.7 for nurse/midwives.¹ This represents a substantial increase from phase III, making health workforce a priority for countries like India that are looking to advance to phase IV.