Challenges

Despite substantial advancements in reducing neonatal and maternal mortality over the past decades, India's higher mortality states still face ongoing challenges that will affect future progress. States like Madhya Pradesh, Odisha, Rajasthan, and Uttar Pradesh have overcome obstacles, but persistent challenges must be addressed as these states continue their efforts to lower neonatal and maternal mortality rates.

Lingering inequalities in coverage

As detailed in the prior section, equity gaps persist in crucial coverage indicators. For the majority of these indicators, wealthier and urban households exhibit higher coverage than their poorer and rural counterparts, particularly for accessing more advanced forms of intrapartum care. Also, there is substantial variation in coverage based on factors like maternal education. Even within the cluster of states with higher mortality rates, state-level differences in several key indicators are evident.

Inequities in intervention coverage also translate to differences in neonatal mortality, as evidenced from an analysis of the 2019–2021 NFHS. This analysis found that neonatal mortality rate (NMR) was 1.6 times higher among the poorest tertile than the richest tertile—35.8 versus 22.3 neonatal deaths per 1,000 live births.¹ Similarly, NMR in rural areas was 1.3 times higher than in urban areas at 32.6 versus 24.9 neonatal deaths per 1,000 live births.¹

National-level pro-poor and pro-rural policies, in tandem with state-specific initiatives in the higher mortality state cluster, have contributed to the mortality reductions observed, particularly in poorer and more rural communities. However, these gaps persist and are wider in the higher mortality state cluster than in the lower mortality state cluster, which may in part be related to ongoing discrepancies in the quality of care they receive. Tracking and reduction of these gaps will be key as the higher mortality state cluster seeks to further reduce mortality and advance to the next phases of the integrated mortality transition framework.

Place of delivery

Although the higher mortality state cluster has experienced a rapid increase in institutional delivery, a substantial portion of these deliveries occur outside of hospital settings. As of the 2019–2021 NFHS, 59.3%, 55.4%, 57.9%, and 51.8% of institutional deliveries in Madhya Pradesh, Odisha, Rajasthan, and Uttar Pradesh respectively occurred in lower-level health facilities.¹ In contrast, in the lower mortality Exemplar states of Maharashtra and Tamil Nadu, only 18.9% and 19.2% of institutional deliveries respectively occurred in lower-level health facilities.¹

Although the higher mortality state cluster, and especially the higher mortality Exemplar states, have taken substantial measures to improve the quality of care at lower-level health facilities, the integrated maternal transition framework suggests that a continued shift toward hospital-based delivery is a key element of sustained mortality reduction and progression to phase IV. The integrated mortality transition framework analysis found that among phase III countries, the median hospital delivery rate was 48.2% but by phase IV this had increased to 72.8%.² This suggests that continued efforts to improve quality of care—including shifts in types of facilities women are delivering in—will be key for the higher mortality state cluster.