Why is India an Exemplar?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal mortality rate (NMR) and maternal mortality ratio (MMR)—beyond what may be attributable to their socioeconomic progress alone. Figure 2 shows the association between NMR/MMR declines and increases in the gross national income (GNI) per capita across low- and middle-income countries with populations of at least 2 million that have not yet reached the NMR/MMR Sustainable Development Goal targets. A fitted linear regression line is overlaid, indicating the expected relationship between mortality change and GNI per capita change. Countries falling below the fitted line are those that have experienced faster declines in mortality than what would be expected based on their GNI per capita increases alone. India falls substantially below this line for both NMR and MMR, suggesting that the country’s mortality reductions have outpaced the rate of mortality reduction that would be expected based on its economic development alone.

India’s mortality trends are described throughout this section and are contextualized within India’s four major national health policy periods as shown in Figure 3. These include the 1992–1997 Child Survival and Safe Motherhood (CSSM) program, the 1997–2005 Reproductive and Child Health I (RCH I) period, the 2005–2012 Reproductive and Child Health II/National Rural Health Mission (RCH II/NRHM) period, as well as the 2012–2020 National Health Mission/Reproductive, Maternal, Newborn, Child, and Adolescent Health (NHM/RMNCH+A) period. Additional information and context for each of the four policy periods—especially the influential RCH II/NRHM period—can be found in the How Did India Implement section. In-depth descriptions of higher and lower mortality state cluster trends are available in more depth within their respective narratives.

Maternal mortality

India stands out clearly as an Exemplar country for its reduction in maternal mortality over the last several decades. India’s Sample Registration System (SRS) shows an MMR decline from 327 to 103 maternal deaths per 100,000 live births between 2000 and 2018, as shown in Figure 4.¹ While maternal mortality has experienced a steady decline overall since 2000, progress accelerated slightly during the RMNCH+A/NHM period at an average annual rate of change (AARC) of -8.1% between 2012 and 2018.¹ This trend was particularly strong for the higher mortality state cluster, which experienced an AARC of -8.8% during the RMNCH+A/NHM period.¹ The gap between higher and lower mortality state clusters narrowed substantially between 2000 and 2018, decreasing from 263 to 76 maternal deaths per 100,000 live births.¹

India’s Million Death Study (MDS) in 2005–2006 found that 27% of maternal deaths in India were attributable to hemorrhage, making it the largest contributor to MMR overall.² This was followed by sepsis, which contributed 17% of maternal deaths in India nationally according to the same study.² Findings from the Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) Study supports this finding, with hemorrhage and sepsis representing the largest causes of maternal death in 2000—respectively accounting for 42% and 12% of maternal deaths.³ Both of these causes have declined over time according to GBD estimates, respectively accounting for 36% and 5% of maternal deaths in India by 2019.³ Together, this evidence indicates that direct causes contributed a declining portion of maternal deaths over the last two decades, as indirect causes have increasingly constituted a rising percentage of maternal deaths.

Neonatal mortality

India’s SRS data show a reduction in NMR from 43.2 to 22.7 neonatal deaths per 1,000 live births from 2000 to 2018, as shown in Figure 5.¹ Similar to MMR, declines in NMR have been steady over recent decades, with the most rapid gains experienced during the 2012–2020 RMNCH+A/NHM period, during which the AARC was -3.9%.¹ While progress has been steady in both the higher and lower mortality state clusters, the gap between clusters has stayed consistent in recent decades. This has resulted in an ongoing lag in progress between the state clusters as they continue to progress, with levels of NMR in the lower mortality state cluster generally about twelve years ahead of the levels of NMR in the higher mortality state cluster.

Assessments of cause-specific neonatal mortality identified that reductions in asphyxia/birth trauma and infections were central to overall NMR progress, as shown in Figure 6. According to India’s Million Death Study (MDS), between 2000 and 2015, NMR from asphyxia/birth trauma declined from 9 to 2 neonatal deaths per 1,000 live births.⁴ Findings from the World Health Organization (WHO) Maternal and Child Epidemiology Estimation (MCEE) group also suggest substantial progress in asphyxia/birth trauma, which was estimated to have decreased from 12 to 6 neonatal deaths per 1,000 live births between 2000 and 2019.⁵ These two sources similarly reported major declines in NMR due to infection, with the MDS suggesting a decline from 15 to 5 neonatal deaths per 1,000 births between 2000 and 2015 and the WHO MCEE estimating a reduction from 13 to 4 neonatal deaths per 1,000 live births between 2000 and 2019.^4,5