In the past several decades, a pattern of rapid increases in cesarean delivery rates has been observed worldwide, and this increase has varied across regions.¹ Although these rates have increased at a slow pace in countries within sub-Saharan Africa,² they are increasing at a substantial rate in many other countries. For instance, in the US, the cesarean delivery rate reached 30% in 2006, partly owing to the practice of preventive medicine and the threat of litigation.³ In European countries, the cesarean delivery rates vary from 52.2% in Cyprus to 14.8% in Iceland, with rates in the United Kingdom ranging from 24.6% in England to 29.9% in Northern Ireland.⁴ Australia’s cesarean delivery rate increased from less than 20% in 1998 to approximately 30% in 2008.⁵ Moreover, in Asia, an increase in cesarean delivery rates has been observed in a number of countries, including India, Nepal, China, and Bangladesh.⁶ Such a substantial increase in cesarean delivery rates without an indication of benefits for maternal or neonatal health has become a major public health concern.⁷

Background: Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997–2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India. Methods: This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015–16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India. Results: On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors. Conclusions: The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India’s impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

Introduction: Cardiovascular disease (CVD) is the single largest contributor to non-communicable disease (NCD) deaths, with hypertension contributing to a significant proportion of these deaths. This study aims to provide estimates of the prevalence, awareness, treatment and control of hypertension at sub-national levels in India and identifies well and under-performing states with respect to the diagnosis and treatment of hypertension.Methods: The study utilises data from the Longitudinal Study of Ageing in India (LASI), a nationally representative survey of more than 72,000 individuals. Age-sex adjusted prevalence rates of self-reported hypertension was calculated using the direct standardisation method. Multivariable logistic regression was performed to assess the association of self-reported hypertension with the various individual co-morbidity, lifestyle, and household factors. Self-reported prevalence was compared with an objective measure of hypertension for each state, and funnel plots were constructed to assess the performance of states.Results: Our findings suggest that the overall prevalence of age-sex adjusted self-reported hypertension was 25.8% in India with significant variation among states. Results based on logistic regression confirm that those individuals who are elderly, obese, belong to a higher socio-economic group and have associated co-morbidities are at increased odds of reporting hypertension. Overall, 4 out of 10 adults over 45 years of age in India are not aware of their hypertensive condition, and of those who are aware, 73% are currently taking medication, and only 10% of these have their hypertension under control. Based on the performance, states were classified into high and low performing categories. States with an increased proportion of population below the poverty line had significantly lower performance with respect to the diagnosis of hypertension, whereas states with higher literacy rates and greater availability of specialist doctors at community health centres (CHCs) had significantly better performance with respect to treatment-seeking behaviour.Conclusion: The findings of this study and its policy implications are discussed. Based on state performance, strategies are proposed in terms selective targeting vs. population-based strategies. High impact states and sub-groups are identified where intense efforts are needed to tackle the growing menace of hypertension in India.

Objectives This paper analyses the patterns and trends in the mortality rates of infants and children under the age of 5 in India (1992–2016) and quantifies the variation in performance between different geographical states through three rounds of nationally representative household surveys. Design Three rounds of cross-sectional survey data. Setting The study is conducted at the national level: India and its selected good-performing states, namely Haryana, Kerala, Maharashtra, Punjab and Tamil Nadu, and selected poor-performing states, namely Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh. Participants Adopting a multistage, stratified random sampling, 601 509 households with 699 686 women aged 15–49 years in 2015–2016, 109 041 households with 124 385 women aged 15–49 years in 2005–2006, and 88 562 households with 89 777 ever married women in the age group 13–49 years in 1992–1993 were selected. Results Through the use of maps, this paper clearly shows that the overall trend in infant and child mortality is on a decline in India. Computation of relative change shows that majority of the states have witnessed over 50% reduction in both infant and under-5 mortality rates from National Family Health Survey (NFHS)-I to NFHS-4. However, the improvements are not evenly distributed, and there is huge variation in performance between states over time. Funnel plots show that the most populous states like Uttar Pradesh Bihar and Madhya Pradesh have underperformed consistently across the survey period from 1992 to 2016. Regression analysis comparing high-performing and low-performing states revealed that female infants and women with shorter birth intervals had greater risk of infant deaths in poor-performing states. Conclusion Attempts to reduce infant and child mortality rates in India are heading in the right direction. Even so, there is huge variation in performance between states. This paper recommends a mix of strategies that reduce child and infant mortality among the high-impact states where the biggest improvements can be expected, including the need to address neonatal mortality.