Benchmarking progress in lower mortality Exemplar states

While lessons from lower 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 lower 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 lower mortality state cluster in the integrated maternal, neonatal, and stillbirth mortality transition framework

Learnings from a multi-country analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework, may prove useful as lower 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.

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.

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 lower mortality state cluster advanced from mid-phase II to early phase IV. As part of this progression through phases, the lower mortality state cluster has undergone improved coverage of key health indicators, such as ANC and institutional delivery, a greater portion of delivery care at hospitals, higher quality of care provided, a sharp reduction in the burden of direct causes of death such as infections, and narrowing equity gaps in several key indicators. This framework suggests that continued improvements in quality of care and accelerated expansion of human resources for health will be key factors as the lower mortality states seek to advance through phase IV and into phase V.

In particular, narrowing of equity gaps is associated with advancement into phase V to ensure that all groups are benefiting from high-quality maternal and newborn health (MNH) services. As such, the following section of this report will highlight trends in health care equity for key reproductive, maternal, newborn, child and adolescent health (RMNCH) indicators. Several key national policies in India, such as Janani Suraksha Yojana (JSY) 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 lower 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 lower mortality states look to continue reducing mortality, ultimately progressing to phase V. These factors include improved equity in health service coverage, addressing deaths 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

In the last three decades, family planning demand satisfied in the lower mortality state cluster has been largely equitable across the dimensions of wealth and residence. As shown below in Figure 20, the lower mortality cluster had already achieved relatively equitable family planning coverage by the 1992–1993 NFHS. As of the 2019–2021 NFHS, demand satisfied was 0.4% higher among the wealthiest tertile compared to the poorest tertile and 2.5% higher among rural populations compared to urban populations in the lower mortality state cluster.

Trends are generally similar for the Exemplar states of Maharashtra and Tamil Nadu, with minimal gaps in demand satisfied over time. In contrast, India nationally had notable gaps at the time of the 1992–1993 NFHS, which have declined over time.

Family planning is a key factor influencing total fertility rate, which was 2.1 births per woman in 2019 for the lower mortality state cluster.

Looking ahead, the median total fertility rate for phase V is 1.6 births per woman. This small disparity suggests that fertility decline will play a minimal role in further mortality gains despite its impact in the past several decades.

Antenatal care

Across India, there was a substantial improvement in equitable ANC4+ coverage between the 2005–2006 NFHS and 2015–2016 NFHS, as shown below in Figure 21. However, for the lower mortality state cluster, this progress was particularly substantial. As of the 2019–2021 NFHS, in the lower mortality state cluster, ANC4+ coverage was 7.4 percentage points higher for the wealthiest tertile than the poorest tertile and 3.7 percentage points higher for urban populations than rural populations.

In contrast, these coverage gaps were respectively 25.2% and 14.4% points for India nationally. The lower mortality Exemplar state of Maharashtra experienced equity trends that closely mirror the overall lower mortality cluster. Tamil Nadu, on the other hand, had consistently narrower equity gaps over the last three decades.

The integrated transition framework found that typical ANC4+ coverage levels for phase IV range from 84.1% to 94.3%, whereas typical ANC4+ coverage levels for phase V range from 84.2% to 95.3%.

Although coverage of ANC4+ in the lower mortality state cluster is generally equitable, progress is needed across wealth and residence gradients to reach these ranges.

Institutional delivery

Equity trends for institutional delivery in the lower mortality state cluster are similar to ANC, with major progress occurring between the 2005–2006 NFHS and 2015–2016 NFHS, as shown below in Figure 22. This progress was also reflected throughout India, including in the higher mortality state cluster. Similar to the equity trend for ANC, Tamil Nadu showed historically equitable coverage in institutional delivery. As of the 2019–2021 NFHS, the wealthiest tertile in the lower mortality cluster had an institutional delivery rate 10.1 percentage points higher than the poorest tertile, whereas urban communities had an institutional delivery rate 2.5 percentage points higher than rural communities.

In Tamil Nadu, these values were respectively 2.0 and 0.4 percentage points, reflecting the state’s particularly minimal equity gaps in coverage over the years.

Institutional delivery rates in the lower mortality state cluster markedly improved in recent decades and are comparable to values typically seen in both phases IV and V.

The lower mortality states also have relatively high delivery rates in hospitals and more advanced facilities, in line with trends usually observed for later phases of the transition.

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 disparity is linked to rising rates of C-section overall (including elective cases) in recent years, especially among wealthier, urban populations more likely to access care at private facilities. Assessing C-section rates among the poorest 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 1.3% compared to 8.1% among the wealthiest tertile.

By the 2019–2021 NFHS, these C-section rates had respectively increased to 18.5% and 42.3%, as shown below in Figure 23.

The integrated mortality transition framework specifically considers the C-section rate among the poorest as a key indicator to mitigate biases related to elective C-section among the wealthiest communities. C-section rate among people with low income in India’s lower mortality state cluster is within the range of typical values for phase IV and, looking ahead, is also within the range of typical values for phase V.

Deaths caused by indirect health factors

As countries move through the transition framework, the proportion of maternal and neonatal deaths attributable to direct causes such as infections typically declines. This trend is generally accompanied by a rise in the percentage of deaths associated with indirect health factors. For instance, analysis of the transition framework revealed that across countries, the median percentage of neonatal deaths from infections dropped from 27.9% to 7.3% between phases I and V.

As previously noted in this report and in national research, the percentage of maternal and neonatal deaths from infections has decreased in India’s lower mortality state cluster, reflecting the general pattern observed worldwide. Consequently, to continue reducing overall mortality, it becomes increasingly vital to address deaths related to indirect causes. Risk factors like maternal anemia, diabetes, hypertension, low birthweight, and preterm birth will become priority areas requiring more integrated health sector responses as lower mortality states aim to further decrease mortality and progress to the next phase of the transition framework.

Expanded health workforce and infrastructure

This report outlines various strategies that states from India’s lower mortality cluster have implemented over the past 20 years to enhance and empower health care providers, contributing to reductions in neonatal and maternal mortality rates. In acknowledging these improvements, it is also important to highlight that the ongoing expansion and enhancement of the health care workforce will be crucial as the states look to advance to phase V of the transition framework. Particularly, having skilled health care personnel capable of identifying and managing complications will be essential as deaths from more indirect causes become proportionally more common.

The transition framework emphasizes that the health workforce densities in phases IV and V are significantly higher than those in phase III. The median density of nurse/midwives per 10,000 people doubles from 13.1 to 27.9 between phases III and IV, then nearly triples to 79.8 by phase V.

Increases are sharp for physician density as well—increasing from 3.6 to 20.5 to 34.2 physicians per 10,000 people over phases III, IV, and V. Although the lower mortality state cluster has taken steps to expand its health workforce, the transition framework highlights that more needs to be done to reach these values.