Why are Maharashtra and Tamil Nadu Exemplar states?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal mortality rate (NMR) and maternal mortality ratio (MMR)—beyond what can be attributable to their socioeconomic progress alone. More information about how India was identified as an Exemplar country is available in the national-level report.

Within India, states were grouped into two clusters based on their baseline per capita income and mortality levels in 2000, according to India’s sample registration system (SRS).¹ The higher and lower mortality state clusters were then both assessed to identify which states within each cluster had achieved the most rapid mortality declines. As shown below in Table 1, the average annual rate of change (AARC) for both NMR and MMR decline were summed for each state, and states with the largest summed AARC values were chosen as Exemplar states. Maharashtra and Tamil Nadu were identified as Exemplar states because their summed AARC values were the highest among lower mortality cluster states. Maharashtra showed the most rapid MMR decline of all lower mortality cluster states and the second-quickest NMR reduction. Similarly, Tamil Nadu experienced the most accelerated NMR reduction of all lower mortality cluster states and the fifth most rapid MMR reduction. Table 1 below also shows the rates of change in higher mortality states for comparison.

Mortality trends for India’s lower mortality state cluster are described throughout this section, contextualized within India’s four major national health policy periods, shown below in Figure 2. These include the 1992–1997 Child Survival and Safe Motherhood (CSSM) program, the 1997–2005 Reproductive and Child Health I (RCH-I) period, the 2005–2012 Reproductive and Child Health II/National Rural Health Mission (RCH-II/NRHM) period, as well as the 2012–2020 National Health Mission/Reproductive, Maternal, Newborn, Child and Adolescent Health (NHM/RMNCH+A) period. Additional information and context for each of these periods—especially the influential RCH-II/NRHM period—can be found in the How did India implement section of the national-level report. This report focuses on state-specific trends and factors within the lower mortality cluster Exemplar states.

Maternal mortality

Nationally, India’s maternal mortality ratio (MMR) declined from 327 to 103 maternal deaths per 100,000 live births between 2000 and 2018.¹ Over this time span the lower mortality state cluster experienced an MMR reduction of 198 to 69 maternal deaths per 100,000 live births, as shown below in Figure 3.¹ The rates of MMR decline in the lower mortality Exemplar states of Maharashtra and Tamil Nadu outpaced progress in the broader lower mortality state cluster. In Maharashtra, MMR declined from 169 to 38 maternal deaths per 100,000 live births between 2000 and 2018.¹ Progress in reducing MMR accelerated after 2005 in the 2005–2012 RCH-II/NRHM and 2012–2020 NHM/RMNCH+A policy periods, which respectively experienced maternal mortality AARCs of -9.3% and -9.7%.¹ In Tamil Nadu, MMR decreased from 167 to 58 maternal deaths per 100,000 live births between 2000 and 2018.¹ MMR declines were most rapid in Tamil Nadu during the 1997–2005 RCH-I policy period at an AARC of -8.2%.¹

This study leveraged data from India’s Million Death Study (MDS) and the Institute for Health Metrics’ Global Burden of Disease (GBD) to examine how causes of maternal death differed across state clusters.^2,3 In the lower mortality state cluster, a relatively lower portion of maternal deaths were caused by hemorrhage and abortion-related complications, whereas a relatively higher portion of maternal deaths were caused by sepsis, hypertensive disorders, and obstructed labor.

In recent decades, India has seen a transition from direct causes of death like hemorrhage and infection to indirect causes related to the overall health condition of the mother. This shift is described in more detail in the national-level report. The lower mortality state cluster in particular has made progress in mitigating the burden of direct causes of death, with a growing portion of maternal mortality increasingly linked to indirect causes in the lower mortality state cluster.

Neonatal mortality

Between 2000 and 2018, NMR in India declined from 43.2 to 22.7 neonatal deaths per 1,000 live births.¹ As shown below in Figure 4, NMR in the lower mortality state cluster declined from 35.1 to 15.4 neonatal deaths per 1,000 live births during this same period.¹ NMR declines in the lower mortality cluster Exemplar states of Maharashtra and Tamil Nadu were particularly rapid. Between 2000 and 2018, NMR in Maharashtra decreased from 31.0 to 13.0 neonatal deaths per 1,000 live births, whereas NMR in Tamil Nadu decreased from 34.5 to 10.3 neonatal deaths per 1,000 live births.¹ In both lower mortality cluster Exemplar states, progress was accelerated most during the 2005 to 2012 RCH-II/NRHM policy period. Maharashtra and Tamil Nadu respectively experienced neonatal mortality AARCs of -5.5% and -7.9% during this period.¹

India’s Million Death Study assessed cause-specific neonatal mortality for a subset of wealthier Indian states highly similar to the lower mortality state cluster as defined in this study.² The percentage of neonatal deaths caused by infections among these states declined from 17% to 12%.² There was also a decline in neonatal deaths caused by birth trauma and asphyxia, which represented 20% of neonatal deaths in 2000 but only 14% by 2015.² Consequently, preterm birth and related complications increasingly represented a larger portion of neonatal deaths over time—37% in 2000 but 47% in 2015.² The portion of neonatal deaths attributable to congenital anomalies almost doubled over this time period, from 5% to 9%.²

This evidence is supported by Global Burden of Disease (GBD) estimates from the Institute for Health Metrics and Evaluation at the state level. According to GBD estimates, as of 2019, infections constituted only 14% of neonatal deaths in Maharashtra and 10% of neonatal deaths in Tamil Nadu.³ The GBD also found that a growing portion of deaths in the lower mortality Exemplar states can be linked to causes such as preterm birth.

One key difference that emerged between the higher and lower mortality state clusters was progress with respect to the timing of neonatal death. In the lower mortality state cluster, neonatal mortality declined most quickly in the first days of life—days 0 to 2.¹ Because mortality attributable to intrapartum causes is more common in the first days of life, this evidence supports findings that these causes have experienced the most rapid declines. In contrast, the higher mortality state cluster has experienced more rapid declines after the first days of life, linked to reductions in infection-related mortality.