Benchmarking progress in higher mortality Exemplar states

While lessons from higher mortality Exemplar states are designed to provide insights for peer states, Exemplar states themselves can benefit from comparisons across settings. Contextualizing the progress of India’s higher mortality Exemplar states in a broader framework can provide insight into aspects of maternal and newborn health the states have particularly excelled in, while also identifying opportunities for further improvement.

Positioning India’s higher mortality state cluster in the integrated maternal, neonatal, and stillbirth mortality transition framework

Lessons from a multi-country analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework, might prove useful as higher mortality states look to further reduce NMR and MMR. In this framework, maternal and peri-neonatal mortality (neonatal mortality including stillbirths) are categorized into five phases, with phase I indicating highest mortality and phase V indicating lowest mortality.¹ This transition framework tool can be used to benchmark a country’s progress and chart a path to future 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 below in Figure 18. 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, in-facility delivery, skilled birth attendance, and postnatal care improved, in part because of an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in phase III because 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 accessible only 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 below in Figure 19. During this same period, the higher mortality state cluster advanced from phase I to early phase III. As part of this progression through phases, the higher mortality state cluster has undergone a substantial fertility decline, seen expansion of health infrastructure, improved coverage of key health indicators like ANC and institutional delivery, and a reduced burden of direct causes of death such as infections. This framework suggests that sustained reduction of infections and other peripartum causes, continued improvements to health service coverage and quality, as well as an accelerated expansion of its human resources for health workforce and capacity will be key for the higher mortality state cluster as it seeks to advance through phase III and into phase IV.

In particular, narrowing equity gaps by helping even the most disadvantaged groups access maternal and newborn health services is associated with advancement into phase IV. As such, the following section of this report will highlight trends in health care equity for key reproductive, maternal, newborn, child and adolescent health indicators. Several key policies in India at the national level, such as Janani Suraksha Yojana and Janani Shushu Suraksha Karyakaram, have sought to minimize inequities in coverage through pro-poor and pro-rural targeting. These policies have included components specifically aimed at mitigating financial and logistic barriers to care—especially institutional delivery. Overall, these efforts have contributed to improvements for poorer and rural communities, though as the following section highlights, gaps remain for key indicators in the higher mortality state cluster.

Factors key for progressing in the mortality transition framework

This framework can also be leveraged to identify factors that could be key as India’s higher mortality states look to continue reducing mortality, ultimately progressing to phases IV and V. These factors include improved equity in health service coverage, addressing deaths in the intrapartum period and increasingly those linked to indirect health factors, and an expanded 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

Compared to other reproductive, maternal, and neonatal health indicators, demand for family planning satisfied by modern methods is relatively equitable across the higher mortality state cluster. As of the 2019–2021 NFHS, demand satisfied for family planning satisfied by modern methods was 0.7% higher among the wealthiest tertile as compared to the poorest tertile, and 0.8% higher among rural populations compared to urban populations, as shown below in Figure 20.² This high degree of equity by the 2019–2021 NFHS is seen across the higher mortality Exemplar states, with Odisha seeing the largest gaps—though poorer and rural communities have higher demand satisfied. Trends over time for higher mortality Exemplar states vary considerably—Madhya Pradesh and Odisha have seen relatively equitable family planning coverage for decades whereas Uttar Pradesh has achieved substantial progress in the past decade.

While other determinants influence fertility rate, family planning is a key factor related to the number of children born to each woman. In 2019, total fertility rate for the higher mortality state cluster was 2.6 births per woman.³ As higher mortality states look to continue mortality reduction, characteristics of future phases can be considered. For example, the median total fertility rate for phase IV is 2.2 births per woman, which declines further to 1.6 births per woman by phase V.¹ This suggests that fertility reduction will continue to be a factor as the higher mortality state cluster advances to lower levels of mortality.

Antenatal care

Trends in equity gaps are more consistent across states for ANC4+ coverage, as shown below in Figure 21. Gaps in coverage tended to increase slightly between the 1992–1993 NFHS and 2005–2006, but these gaps then narrowed by the 2019–2021 NFHS. As of this most recent survey, in the higher mortality state cluster, ANC4+ coverage was 21.7 percentage points higher in the wealthier tertile than the poorest tertile and 11.3 percentage points higher among urban communities than rural communities.² This represents an improvement from the 2005–2006 NFHS when those gaps were respectively 39.9 percentage points and 26.7 percentage points.⁴ Though trends follow a relatively consistent pattern across higher mortality Exemplar states, Rajasthan and Odisha were found to have the smallest gaps in ANC4+ coverage by both wealth and residence as of NFHS 2019–2021.

According to the integrated transition framework, typical ANC4+ coverage levels for phase III range from 55% to 81.1%.¹ While ANC4+ coverage in the higher mortality state cluster has improved and become more equitable over time, it still has room for improvement to reach these ranges. Looking forward, coverage levels in phases IV and V are higher, with a minimum of 84% coverage.¹

Institutional delivery

Similar to antenatal care, equity gaps in institutional delivery have undergone substantial progress since the 2005–2006 NFHS, as shown below in Figure 22. In the higher mortality state cluster between the 2005–2006 NFHS and 2015–2016 NFHS, the gap in institutional delivery rate between the wealthiest and poorest tertiles narrowed from 48.2 percentage points to 25.8 percentage points while the gap in institutional delivery rate between urban and rural communities narrowed from 31.9 percentage points to 11.9 percentage points.^2,4 All higher mortality Exemplar states had institutional delivery equity gaps that were narrower than the overall higher mortality state cluster equity gaps. In particular, Rajasthan stood out in the 2019–2021 NFHS survey for having particularly narrow gaps in institutional delivery rates across the dimensions of wealth and residence.

Institutional delivery rates in the higher mortality state cluster are high for phase III and are near the levels typical for phase IV.¹ However, the relatively low delivery rate in hospitals represents an opportunity for improvement because countries in later phases of the transition framework typically experience a growing portion of deliveries in facilities with greater capacity to address birth complications and to avert intrapartum deaths.

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 phenomenon is linked to rising rates of C-section in recent years, especially among wealthier, urban populations more likely to access care at private facilities, which tend to have higher rates. Assessing C-section rates among the poorest patients can provide valuable insight into how accessible the intervention is to all populations, in cases more likely to be medically necessary.

At the time of the 1992–1993 NFHS, the C-section rate among the poorest tertile was 0.2% compared to 2.5% among the wealthiest tertile, as shown in Figure 23 below.⁵ By the 2019–2021 NFHS, these C-section rates had respectively increased to 6.8% and 27.4%.²

The integrated mortality transition framework helps to contextualize this C-section rate among the poorest. C-section rate among those with low income in India’s lower mortality state cluster is within the range of typical values for phase III, and looking ahead, is nearly within the range of typical values for phase IV.¹

Deaths caused by intrapartum and indirect health factors

As countries advance through the transition framework, the share of maternal and neonatal deaths caused by direct factors such as infections usually declines. This decline is typically met with a simultaneous increase in the proportion of deaths during the intrapartum period and increasingly, linked to indirect health status issues. For example, analysis of the transition framework showed that, across countries, the median percentage of neonatal deaths caused by infections decreased from 27.9% to 7.3% between phases I and V.¹

As highlighted earlier in this report and supported by national research, the percentage of maternal and neonatal deaths from infections has dropped in India's higher mortality state cluster, mirroring global trends. To continue decreasing neonatal and maternal mortality, it is increasingly important to address deaths associated with indirect causes. Risk factors like maternal anemia, diabetes, hypertension, low birthweight, and preterm birth will need more integrated health sector responses as regions with lower mortality aim to further reduce mortality rates and progress through the next phases of the transition framework.

Expanded health workforce and infrastructure

This study highlights several strategies that states in India's higher mortality cluster have used over the last two decades to strengthen and support health care providers, helping to reduce neonatal and maternal mortality rates. While recognizing these advancements, it is crucial to note the need for continued growth and improvement of the health care workforce as the states progress to phase V of the transition framework. Specifically, equipping skilled health care workers who can handle complications with adequate supplies such as blood banks and anesthesia will be essential as deaths from indirect causes become more prevalent.

The transition framework indicates that the health workforce densities in phases IV and V are much larger than those in phase III. The median density of nurses/midwives per 10,000 population rises from 13.1 in phase III to 27.9 in phase IV, then nearly triples to 79.8 in phase V.¹ Similarly, physician density increases markedly—from 3.6, to 20.5, to 34.2 physicians per 10,000 people across phases III, IV, and V.¹ Although the higher mortality state cluster has made efforts to expand its health workforce, the transition framework suggests that further expansion will be crucial as higher mortality states look toward continued improvements.