The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India

INTRODUCTION: Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings. METHODS: We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015–2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India. RESULTS: We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant. CONCLUSION: Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.