Has India's national rural health mission reduced inequities in maternal health services? A pre-post repeated cross-sectional study

In 2005, India launched the National Rural Health Mission (NRHM) to strengthen the primary healthcare system. NRHM also aims to encourage pregnant women, particularly of low socioeconomic backgrounds, to use institutional maternal healthcare. We evaluated the impacts of NRHM on socioeconomic inequities in the uptake of institutional delivery and antenatal care (ANC) across high-focus (deprived) Indian states.Data from District Level Household and Facility Surveys (DLHS) Rounds 1 (1995-99) and 2 (2000-04) from the pre-NRHM period, and Round 3 (2007-08), Round 4 and Annual Health Survey (2011-12) from post-NRHM period were used. Wealth-related and education-related relative indexes of inequality, and pre-post difference-in-differences models for wealth and education tertiles, adjusted for maternal age, rural-urban, caste, parity and state-level fixed effects, were estimated.Inequities in institutional delivery declined between pre-NRHM Period 1 (1995-99) and pre-NRHM Period 2 (2000-04), but thereafter demonstrated steeper decline in post-NRHM periods. Uptake of institutional delivery increased among all socioeconomic groups, with (1) greater effects among the lowest and middle wealth and education tertiles than highest tertile, and (2) larger equity impacts in the late post-NRHM period 2011-12 than in the early post-NRHM period 2007-08. No positive impact on the uptake of ANC was found in the early post-NRHM period 2007-08; however, there was considerable increase in the uptake of, and decline in inequity, in uptake of ANC in most states in the late post-NRHM period 2011-12.In high-focus states, NRHM resulted in increased uptake of maternal healthcare, and decline in its socioeconomic inequity. Our study suggests that public health programs in developing country settings will have larger equity impacts after its almost full implementation and widest outreach. Targeting deprived populations and designing public health programs by linking maternal and child healthcare components are critical for universal access to healthcare