While India has made remarkable progress in reducing neonatal and maternal mortality in recent decades, challenges remain that will influence the country’s future progress. India has risen to meet previous challenges, and in this section, we describe select challenges that may be top priorities as the country continues improving neonatal and maternal health.
Lingering inequalities in coverage
As described in the previous section, equity gaps remain for key coverage indicators, such as antenatal care. For most indicators, coverage is higher for richer and urban households than for poorer and rural households, and there is substantial variation in coverage across other related dimensions such as maternal education and caste. State-level variation—especially across higher and lower mortality state clusters—is particularly wide, as discussed throughout this narrative synthesis.
Evidence from the most recent 2019–2021 NFHS highlights that inequities in intervention coverage and quality also translate to differences in neonatal mortality. In this survey, the neonatal mortality rate (NMR) was twice as high for the poorest tertile as it was for the richest tertile—32.8 compared with 16.0 neonatal deaths per 100,000 live births.1 Similarly, NMR in rural areas was 1.5 times higher than in urban areas—27.4 compared with 18.0 neonatal deaths per 100,000 live births.1
India has implemented several pro-poor and pro-rural policies meant to increase financial and physical access to essential maternal and newborn care, contributing to the mortality reductions observed in poorer and more rural communities.2 However, the persistence of these gaps highlights that these populations continue to face adverse health outcomes. These gaps are particularly pronounced in the higher mortality state cluster and are generally narrower in the lower mortality state cluster. Looking forward, continuing to target rural, poor, and other disadvantaged communities remains an opportunity for further improvement—especially in regard to receiving more advanced forms of care, such as emergency obstetric care (EmONC) more quickly or with higher levels of quality when needed.
Shift from access to quality
Several indicators highlighted throughout this narrative synthesis highlight inequalities in coverage. In the past decade, India has also experienced a growing shift towards a focus on quality of care rather than coverage. As the higher mortality state cluster improves coverage across key indicators, it is therefore also essential to consider markers of quality as well.
For example, while institutional delivery rates across both state clusters have seen remarkable progress, the composition of the types of facilities where deliveries occur varies substantially across state clusters. In the higher mortality state cluster, 40.1% of deliveries occurred in community health centers (CHCs) and primary health centers (PHCs), while district hospitals and private facilities were the place of delivery for 20.4% and 20.1% of births, respectively, in 2018.1 In contrast, in the lower mortality state cluster, fewer births (18.5%) took place at CHCs and PHCs in the lower mortality state cluster.1 In tandem, 36.3% of deliveries in the lower mortality state cluster occurred in district hospitals and 37.4% in private facilities.1 While delivery in a higher-level facility does not guarantee a higher quality of care, it is associated with improved access to commodities, equipment, and highly trained health professionals.
Similarly, comparing the ratio of quality ANC coverage to any antenatal care (ANC) coverage across state clusters highlights that quality of ANC is generally higher in the lower mortality state cluster than in the higher mortality state cluster. In 2018, 85.4% of women in the higher mortality state cluster who received any ANC received quality ANC, while in the lower mortality state cluster 97.4% of women who received any ANC received quality ANC.1
India has also taken many measures to strengthen the capacity of its health workforce, especially as it relates to training skilled birth attendants.3 The country has also enhanced several lower-level facilities to help increase access to comprehensive care outside of hospitals—such as upgrading CHCs to FRUs.4 As India looks to continue mortality reductions and advance to phase IV nationally, continuing to prioritize quality of care will be crucial, especially in the higher mortality state cluster.
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1
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), India, 2019-21: India. Mumbai: IIPS; 2021. Accessed September 10, 2024. https://www.dhsprogram.com/publications/publication-FR374-DHS-Final-Reports.cfm
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2
Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet. 2010;375(9730):2009-2023. https://doi.org/10.1016/s0140-6736(10)60744-1
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3
Chandhiok N, Joglekar N, Shrotri A, Choudhury P, Chaudhury N, Singh S. Task-shifting challenges for provision of skilled birth attendance: a qualitative exploration. Int Health. 2015;7(3):195-203. https://doi.org/10.1093/inthealth/ihu048
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4
World Bank. Implementation Completion Report: India. Child Survival and Safe Motherhood Project (CREDIT 2300-IN). Report No. 16353. World Bank; 1997. Accessed September 10, 2024. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/928031468260333935/india-child-survival-and-safe-motherhood-project