Challenges

Although India’s Exemplar states with lower mortality rates, Maharashtra and Tamil Nadu, have shown substantial advances in decreasing neonatal and maternal deaths over the past few decades, they still face persistent challenges that could affect future progress. These states have successfully addressed prior issues, but these ongoing challenges must be addressed as the lower mortality states seek to continue progress in reducing neonatal and maternal mortality.

Lingering inequalities in coverage

As noted earlier, equity gaps persist in crucial coverage indicators – with exceptions such as institutional delivery in Tamil Nadu. Generally, richer and urban households achieve higher coverage compared to poorer and rural ones. Also, substantial differences exist across other dimensions such as maternal education. Even within states with lower mortality rates, there is marked variation in several key indicators.

An analysis of the most recent 2019–2021 NFHS found that inequities in intervention coverage corresponded to differences in neonatal mortality. According to this analysis, neonatal mortality rate (NMR) was 23.4 neonatal deaths per 1,000 live births among the poorest tertile compared to 11.8 among the wealthiest tertile.¹ This analysis also found that NMR in rural areas was 18.2 neonatal deaths per 1,000 live births compared to 13.5 in urban areas.¹

Lower mortality Exemplar states have implemented several pro-poor and pro-rural policies meant to reduce these coverage and mortality inequities—complemented by centrally run programs. Although these programs have successfully reduced mortality among these vulnerable communities, further progress is necessary to eliminate these inequities. Although these gaps are generally smaller in magnitude in the lower mortality state cluster than the higher mortality state cluster, their continued reduction will be a key factor for sustained progress according to the integrated mortality transition framework and for further advancement of these states into phase V.

High C-section rates

As institutional delivery rates in the lower mortality state cluster have risen, particularly at hospitals, the rate of C-section in the lower mortality state cluster has increased dramatically. C-section rates in the lower mortality state cluster are generally in excess of the 10% to 15% recommendation of WHO, which notes that C-section rates beyond this range are unlikely to confer any additional benefit to mortality reduction.² This guidance also implies that there is no universally ideal C-section rate because C-sections should be administered when necessary. However, C-section rates of the magnitude observed throughout the lower mortality state cluster exceed this range by such a wide margin that overuse of C-section emerges as a challenge.²

The 2019–2021 NFHS found that the institutional C-section rate was 52% among private hospitals and 29% among public hospitals in the lower mortality state cluster.¹ This rate at public hospitals in the lower mortality state cluster is more than double the rate at public hospitals in the higher mortality state cluster—and also two to three times higher than the range suggested by WHO.^1,2 Because C-sections performed when not medically necessary can confer additional health risks, targeting the use of C-section appropriately will be a challenge for the lower mortality state cluster in future years and as these states further reduce mortality and look to advance into phase V.