Safe motherhood and child survival have always been a concern for the policymakers but perinatal mortality, especially stillbirths, have not received due attention [1]. There are 5.9 million perinatal deaths worldwide, almost all of which occur in developing countries. Stillbirths account for over half of all perinatal deaths [2,3]. United Nations’ Millennium Development Goal 4 - reduction in Under-5-Mortality by two thirds by 2015 - would be unattainable without a considerable decline in the perinatal mortality. According to WHO global perinatal estimates for year 2000, one third of stillbirths occur during delivery. These deaths are largely avoidable with skilled care [4]. Institutional deliveries can avert a number of avoidable complications which emerge during child birth by early detection and appropriate management. Although services like emergency obstetric care are the most challenging and costly to provide, they also have the highest potential to save lives [5].

The National Rural Health Mission (NRHM) - initiated in 2005 in India - envisaged providing affordable and quality health care to the poorest households in the remotest regions of the country. This mission has encouraged changes in the pattern of place of delivery. Innovations under NRHM like Janani Surakhsha Yojana (Maternity Security Scheme), Accredited Social Health Activists (ASHA), Delivery Huts, 24×7 Primary Health Centers and Community Health Centers, and Medical Obstetric Care in First Referral Units have paved the way for increased utilization of health institutions for child birth. According to Sample Registration System (SRS), deliveries in govern-ment and private hospitals in India have increased. However, perinatal mortality rate (PNMR) continues to be high, though wide inter-state and intra-state variations exist [6]. The aim of present study was to find whether increase in hospital deliveries is associated with decline in perinatal mortality in rural areas of India after the launch of NRHM.

TABLE I Relative Change in Institutional Delivery and Perinatal Mortality in Rural India from 2005 to 2008

NRHM is a novel initiative by the Government of India to provide health care to people living in the rural areas of relatively poorer states of India. It is evident from the present study that post NRHM there have been a significant rise in hospital deliveries in rural areas (Table I). It was expected that the rise in the institutional delivery will lead to decline in PNMR. A study by WHO in six developing countries had concluded that advancement in institutional care could lead to a decrease in the perinatal mortality [7]. Another study in Mexico also reported that sufficient prenatal care and standards of care for labor, delivery and for the care of the newborn are strong predictors of perinatal mortality [8]. We did not find significant association between the relative rise in hospital deliveries and relative decline in PNMR. Though deliveries in hospitals have increased but quality of delivery care may not be appropriate. Under NRHM focus is on ‘universal institutionalised deliveries’ rather than ‘improved maternal/neonatal health’.

A UN report has highlighted that India is not training a sufficient number of skilled birth attendants and technical senior managers [9]. District Level Household and Facility Survey 2007-08 has revealed substantial gaps in availability of qualified service providers, equipment and supplies in primary and secondary level health facilities in India [10]. Shortage of human resources could be one of the reasons for less than optimum quality of services. Other reason could be non-availability of infrastructure for providing essential newborn care in the hospitals and health centers, e.g., newborn corners where newborns can be given essential care in various levels of health care facilities. All health professionals who attend the mother during child birth should be skilled at resuscitation and know how to recognize babies at risk.

To conclude, although hospital deliveries have increased considerably since the launch of NRHM but PNMR has not shown significant decline. NRHM strategy of increasing institutional delivery rate should look into quality of care issues at the time of greatest risk, i.e., birth and the first few days of life which could be the way forward for reducing the high perinatal death rate in India. However, progress in reducing deaths in perinatal period also depends on other factors like cultural, social and demographic characteristics. These factors also need to be addressed so as to have better impact on perinatal health. Political support and public ownership needs to be developed for accessing the right to health as an entitlement guaranteed by the state not only for those who are alive at birth but also those who die before birth.