Overview

MADHYA PRADESH, ODISHA, RAJASTHAN, AND UTTAR PRADESH: HIGHER MORTALITY EXEMPLAR STATES IN NEONATAL AND MATERNAL MORTALITY REDUCTION

In India, four Exemplar states with higher baseline mortality levels have achieved rapid rates of neonatal and maternal mortality reduction since 2000.

SRS
Contributors
Dr. Ritu Agarwal (IHAT), Dr. Arpita Aggarwal (NHSRC), Dr. Manoj Alagarajan (IIPS), Mr. Kisan Algur (IIPS), Dr. Ramesh BM (UM), Dr. Himanshu Bhushan (NHSRC), Dr. Andrea Blanchard (UM), Prof. James Blanchard (UM), Prof. Ties Boerma (UM), Dr. Diksha Dhupar (NHSRC), Dr. K Madan Gopal (NHSRC), Mr. Shoummo Sen Gupta (IIPS), Dr. Shajy K Isac (IHAT), Prof. KS James (IIPS), Dr. Ashutosh Kothari (NHSRC), Maj. Gen. (Prof) Atul Kotwal (NHSRC), Dr. Prakash Kumar (IIPS), Mr. Thirumalai Narayanan (IHAT), Dr. Mitali Raja (NHSRC), Prof. Usha Ram (IIPS), Dr. Kerry Scott (UM), Ms. Lakshmi Sripada (IHAT), Dr. Reynold Washington (IHAT)

Acknowledgements:

Ministry of Health and Family Welfare, India MNH Exemplars Steering Committee, India MNH Exemplars Technical Working Group, Countdown to 2030, and Other Contributors

Contents

Introduction to the Exemplars study in India

India is a diverse country, with a population that grew from 1.06 billion in 2000 to 1.42 billion by 2022.1 Considering India’s size and diversity, in this analysis, states were grouped into clusters based on their neonatal and maternal mortality levels and per capita incomes. As shown below in Figure 1, these states are accordingly referred to as members of either the higher mortality state cluster or the lower mortality state cluster. While India has made remarkable progress in reducing neonatal and maternal mortality in recent decades, the strategies underlying this progress vary across state clusters. Differences in socioeconomic status and health system capacity by state cluster meant that each cluster faced unique challenges, with maternal and newborn health programming varying by cluster to meet these challenges. As such, Exemplar states within each of the state clusters were identified to highlight lessons from states that had made the most progress from their respective baseline mortality levels.2,3

This narrative tells the story of how four Exemplar states within India’s higher mortality state cluster achieved progress. Additional context can be found in the national-level narrative, with the story of two Exemplar states within the lower mortality cluster highlighted separately as well. Throughout this report, key indicators, interventions, policies, and programs that contributed to neonatal mortality rate (NMR) and maternal mortality ratio (MMR) declines will be featured, highlighting opportunities to learn from Madhya Pradesh, Odisha, Rajasthan, and Uttar Pradesh’s success.

Figure 1: Higher and lower mortality state clusters

Figure 1: Higher and lower mortality state clusters
Author’s Analysis

Fertility decline directly influenced mortality risks and indirectly impacted the broader health system

Improved female education, nutrition, socioeconomic status, and access to family planning contributed to decreases in fertility rates.

Family planning counseling at a district hospital in Uttar Pradesh.
Family planning counseling at a district hospital in Uttar Pradesh.
© Prashant Panjiar
Declines in fertility translate to fewer high-risk pregnancies by way of longer birth intervals, lower birth parity, as well as decreased birth rates specifically among teen girls and older women. While this decline in fertility reduced the number of births per woman, the overall number of births per year in the state cluster remained relatively constant because of population momentum (i.e., fewer births per woman combined with an increased number of women of childbearing age resulted in a relatively steady number of births.) As the health system in the higher mortality state cluster expanded over the last two decades, it didn’t have to keep pace with a growing number of births due to this shift. Empowering women with family planning choices, education, and better socioeconomic opportunities therefore has implications not only for their autonomy and health – but also for the broader health system.

Delivery care in facilities became more accessible, shifting births from homes to health facilities

In the mid-2000s, India shifted towards a focus on promoting institutional delivery. Accredited social health activists and expanded health infrastructure helped to make delivery care more accessible to communities.

A growing network of accredited social health activists (ASHAs) helped to link women to the health system, often accompanying mothers to facilities for deliveries. In the higher mortality state cluster, these facilities were primarily lower-level facilities, which offered skilled birth attendance. Hospitals offering comprehensive care remained less available in the higher mortality states due to persistent capacity gaps. Systems were established to streamline the referral process so that in the case of complications, mothers and newborns could be transferred to more advanced facilities. Exemplar states in the higher mortality state cluster also implemented unique initiatives beyond national programming meant to mitigate barriers to delivering in a health facility. For example, Odisha created maternity waiting homes called Maa Gruha to make it easier for pregnant women in rural areas to stay closer to a health facility around the time of their due date.
An ASHA speaks with a pregnant woman in a rural village within Madhya Pradesh.
An ASHA speaks with a pregnant woman in a rural village within Madhya Pradesh.
© Prashant Panjiar

Pro-poor policies helped the higher mortality states narrow equity gaps in coverage of key MNH services

India instituted conditional cash transfer programs like Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) to incentivize care-seeking. These initiatives particularly helped reduce financial barriers for the most vulnerable groups, among whom coverage increased more rapidly than other groups.

A mother holds her newborn child in the maternal and child health building at a district hospital in Odisha.
A mother holds her newborn child in the maternal and child health building at a district hospital in Odisha.
© Prashant Panjiar
The higher mortality states experienced rapid institutional delivery rates during the mid-2000s following the establishment of the JSY program. This pro-poor initiative helped accelerate progress in the higher mortality state cluster. Exemplar states in the higher mortality state cluster also implemented unique pro-poor policies to complement these national programs. For example, Madhya Pradesh’s Mukhya Mantri Shramik Seva Yojana incentivized antenatal care, institutional delivery, breastfeeding, and newborn vaccination while Odisha’s Shishu Abond Matru Mrutyuhara Purna Nirakaran Abhiyan (SAMPurNA) Yojana program helped to cover the costs of traveling to health facilities especially for delivery care.

Contextualizing the current and future progress of the higher mortality state cluster in an Integrated Mortality Transition Framework

Between 2000 and 2018, the higher mortality state cluster progressed from phase I to early-phase III of the integrated mortality transition framework

This framework helps to highlight the progress that India’s higher mortality state cluster has made in the last two decades, in part linked to fertility decline, increases in health service coverage, and a declining burden of direct causes of maternal and newborn death. In particular, the transition framework allows for comparisons across sub-national regions to learn from their success at every phase and consider how to move towards the next. The framework can thus be leveraged to highlight aspects of maternal and newborn health that may be key to target as states look ahead and continue to reduce NMR and MMR.
Integrated mortality transition framework, 2000-2018.
Integrated mortality transition framework, 2000-2018.
Author's analysis; SRS

Exemplars in Global Health program

The Exemplars in Global Health program aims to learn from countries that have made rapid progress in improving health outcomes and disseminate this evidence to inform health policy and funding decisions. Our aim is to research success stories from low- and middle-income countries and share findings that can be useful for leaders looking to act in comparable contexts.

In selecting Exemplar countries, we reviewed evidence to identify countries that outperformed their peers in vital areas of public health, controlling for factors such as economic growth. In this way, we aim to provide more actionable, policy-relevant insight for stakeholders about how health progress can be made despite resource limitations.

Guided by research partners and technical advisers, we conduct quantitative and qualitative analyses to validate our initial assessments and assess factors that contribute to a country’s exemplary performance. Research in and across Exemplar countries could help ministries, nongovernmental organizations, and multinational bodies address key public health issues in low- and middle-income countries.

By studying proven strategies to prevent disease, malnutrition, and other conditions that burden populations of low- and middle-income countries, we aim to create a list of data-driven narratives that can serve as resources for leaders looking to improving health within their own countries. The following narrative focuses on factors that contributed to Madhya Pradesh, Odisha, Rajasthan, and Uttar Pradesh’s exemplary reductions in neonatal and maternal mortality.

  1. 1
    World Bank. Population, total - India 2021 (1960-2023) [data set]. https://data.worldbank.org/indicator/SP.POP.TOTL?locations=IN
  2. 2
    Ram U, Ramesh BM, Blanchard AK, et al. A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India. BMJ Glob Health 2024;9(suppl 2):e011413. https://doi.org/10.1136/bmjgh-2022-011413
  3. 3
    Bhushan H, Ram U, Scott K, et al. Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India. BMJ Glob Health 2024;9(suppl 2):e011411. https://doi.org/10.1136/bmjgh-2022-011411

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