Maternal Mortality, Stillbirths, and Neonatal Mortality: A Transition Model Based on Analyses of 149 Countries

IntroductionIndia’s progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions.MethodsThe study’s mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews.ResultsIndia’s maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997–1998 and 2017–2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%–94%), quality antenatal care (37%–85%) and institutional delivery (34%–90%) increased, as did caesarean section rates among the poorest tertile (2%–9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005–2012.The 2005–2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women’s empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor.ConclusionRapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study’s integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

Section: Discussionmentioning

confidence: 99%

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

Bhushan,

Ram,

Scott

et al. 2024

“…This mixed-methods study sought to understand the exemplary trends in MMR and NMR reduction within two state clusters of India over the past three decades using the integrated mortality transition model 7. MMR and NMR levels in LMS were around 12 and 16 years ahead of HMS, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…To characterise, compare and understand states’ different mortality transitions over the past few decades, we identified two clusters of states using empirical data on mortality trends by per capita income (PCI). We adapted a five-stage maternal and neonatal mortality transition model developed as part of the global Exemplars in maternal and neonatal mortality reduction study, to examine the state clusters’ transition in five key characteristics: mortality levels, timing and cause of death patterns, health intervention coverage and equity, fertility, and socioeconomic changes 7. Additionally, we assessed how India’s major health policy and systems changes since the 1990s relate to state clusters’ mortality transitions.…”

Section: Introductionmentioning

confidence: 99%

“…Additionally, we assessed how India’s major health policy and systems changes since the 1990s relate to state clusters’ mortality transitions. Guided by the transition model, this study interprets past trends and assesses the current situation in the transition characteristics to help inform future strategies for India’s states and other regions aiming to reach advanced stages of mortality reduction 7…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India

Ram,

Ramesh,

Blanchard

et al. 2024

BackgroundIndia’s progress in reducing maternal and newborn mortality since the 1990s has been exemplary across diverse contexts. This paper examines progress in two state clusters: higher mortality states (HMS) with lower per capita income and lower mortality states (LMS) with higher per capita income.MethodsWe characterised state clusters’ progress in five characteristics of a mortality transition model (mortality levels, causes, health intervention coverage/equity, fertility and socioeconomic development) and examined health policy and systems changes. We conducted quantitative trend analyses, and qualitative document review, interviews and discussions with national and state experts.ResultsBoth clusters reduced maternal and neonatal mortality by over two-thirds and half respectively during 2000–2018. Neonatal deaths declined in HMS most on days 3–27, and in LMS on days 0–2. From 2005 to 2018, HMS improved coverage of antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) by over three-fold. In LMS, ANCq, institutional delivery and PNC rose by 1.4-fold. C-sections among the poorest increased from 1.5% to 7.1% in HMS and 5.6% to 19.4% in LMS.Fewer high-risk births (to mothers <18 or 36+ years, birth interval <2 years, birth order 3+) contributed 15% and 6% to neonatal mortality decline in HMS and LMS, respectively. Socioeconomic development improved in both clusters between 2005 and 2021; HMS saw more rapid increases than LMS in women’s literacy (1.5-fold), household electricity (by 2-fold), improved sanitation (3.2-fold) and telephone access (6-fold).India’s National (Rural) Health Mission’s financial and administrative flexibility allowed states to tailor health system reforms. HMS expanded public health resources and financial schemes, while LMS further improved care at hospitals and among the poorest.ConclusionTwo state clusters in India progressed in different mortality transitions, with efforts to maximise coverage at increasingly advanced levels of healthcare, alongside socioeconomic improvements. The transition model characterises progress and guides further advances in maternal and newborn survival.

“…According to global estimates, maternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000–2017 (66% decline), neonatal mortality from 40 to 21 per 1000 live births during 2000–2018 (48% decline) and stillbirths from 28 to 18 per 1000 births during 2000–2015 (34% decline) 1. This resulted in Nepal moving from phase 2 to phase 3 in the maternal–neonatal–stillbirth transition model 2. Nepal outpaced global and South Asian regional declines in maternal and newborn mortality and stillbirths, after considering its gross national income (GNI) per capita.…”

Section: Introductionmentioning

confidence: 99%

Increased utilisation and quality: a focus on inequality and a learning health system approach—explaining Nepal’s success in reducing maternal and newborn mortality 2000–2020

Sharma,

Campbell,

Oswald

et al. 2024

IntroductionMaternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000–2017 (66% decline). Neonatal mortality dropped from 40 to 21 per 1000 live births during 2000–2018 (48% decline). Stillbirths dropped from 28 to 18 per 1000 births during 2000–2019 (34% decline). Nepal outperformed other countries in these mortality improvements when adjusted for economic growth, making Nepal a ‘success’. Our study describes mechanisms which contributed to these achievements.MethodsA mixed-method case study was used to identify drivers of mortality decline. Methods used included a literature review, key-informant interviews, focus-group discussions, secondary analysis of datasets, and validation workshops.ResultsDespite geographical challenges and periods of political instability, Nepal massively increased the percentage of women delivering in health facilities with skilled birth attendance between 2000 and 2019. Although challenges remain, there was also evidence in improved quality and equity-of-access to antenatal care and childbirth services. The study found policymaking and implementation processes were adaptive, evidence-informed, made use of data and research, and involved participants inside and outside government. There was a consistent focus on reducing inequalities.ConclusionPolicies and programmes Nepal implemented between 2000 and 2020 to improve maternal and newborn health outcomes were not unique. In this paper, we argue that Nepal was able to move rapidly from stage 2 to stage 3 in the mortality transition framework not because of what they did, but how they did it. Despite its achievements, Nepal still faces many challenges in ensuring equal access to quality-care for all women and newborns.