For more than two decades, India’s maternal-health strategy has placed institutional childbirth at the centre of efforts to improve maternal and newborn health. The Janani Suraksha Yojana (JSY), supported by Accredited Social Health Activist (ASHA) workers, has used financial incentives to help women reach health facilities for delivery.
The National Family Health Survey (NFHS-6), conducted in 2023–24, shows how far access has expanded. Institutional births rose from 88.6 percent in NFHS-5 to 90.6 percent in NFHS-6, while births attended by skilled health personnel rose from 89.4 percent to 91.3 percent. The share of women receiving antenatal care also increased, from 92.6 percent to 95.9 percent. Institutional care remains vital, especially when women need emergency obstetric services. But as access expands, progress must also be judged by whether care continues across pregnancy, childbirth and the postpartum period.
That continuity is far from assured. While 95.9 percent of pregnant women received antenatal care, only 65.2 percent had four or more visits – the threshold tracked by NFHS-6 and reflected in India’s antenatal-care guidance. WHO recommends a minimum of eight antenatal contacts, a more demanding measure of continued care that the four-visit figure does not capture. Only 54.9 percent of mothers consumed iron-folic acid tablets for at least 100 days during pregnancy, and 37.8 percent did so for 180 days or more. After delivery, 82.8 percent of mothers and 85.3 percent of newborns received a health check from a health professional within two days. These measures show a gap between initial contact and continued use of services. They do not, on their own, show what care was provided during each contact.
When Institutional Delivery Is Not Enough
As more women give birth in facilities, the appropriateness of care within them becomes harder to overlook. NFHS-6 reports that caesarean deliveries rose from 21.5 percent of births in NFHS-5 to 27.2 percent. The rate was 54.1 percent in private facilities and 16.9 percent in public facilities.
A caesarean section can be lifesaving when medically necessary. The difference between public and private facilities raises questions about access to emergency surgery, referral practices and clinical decision-making. But the rates alone cannot establish whether a caesarean was needed, whether one was unavailable when needed, or why women delivered in particular facilities. Assessing those questions requires evidence on clinical need, facility capacity and patient outcomes. The policy objective is timely, medically appropriate care across both sectors, rather than a particular caesarean rate.
Kerala illustrates why these measures need to be read together. Nearly all births take place in health facilities: 99.7 percent are institutional deliveries and 99.8 percent are attended by skilled health personnel. Yet 41.3 percent are caesarean deliveries, with rates of 39.3 percent in public facilities and 42.5 percent in private facilities. Near-universal facility access tells us little by itself about the reasons for a caesarean or the quality of care surrounding it.
Aligning Incentives with Continuity of Care
India’s maternal-health programmes have been effective at bringing women into contact with the health system. The next task is to make that contact more dependable across the course of care. Policymakers could test ways to recognise sustained antenatal follow-up, timely referrals, postnatal checks and follow-up when recommended care is missed. Any change to ASHA incentives would also depend on clear responsibilities and timely, predictable payments.
Access still requires attention: nearly one in ten births occurs outside a health facility. Maternal-health policy must continue to address barriers to institutional delivery while examining whether women who enter the system receive the care they need at each stage.
The next measure of progress is how reliably the health system connects care before birth, during delivery and after women and newborns return home.