Excess neonatal mortality among private facility births in rural parts of high-mortality states of India: Demographic analysis of a national survey.

Almost one-fourth of neonatal deaths occur in India, many of them in the Empowered Action Group (EAG) states. Research has compared facility births with home births, with limited investigation of mortality differences between births at public and private facilities. We ask how early-life mortality in the rural population of the EAG states and the rest of India differs according to the setting of birth. We consider whether quality of care can help explain the differences we find. Using rural births in India's 2019-21 Demographic and Health Survey, we find that in the rural population of EAG states, neonatal mortality among private facility births is 44 per 1000 (95 % CI: 40-48), compared with 29 per 1000 in public facilities (95 % CI: 27-30) and 38 per 1000 for home births (95 % CI: 34-41). Standardization by socioeconomic status increases the public-private gap. These differences persist even stratifying on key predictors of neonatal mortality. The excess mortality among births to the rural population in private facilities, compared with public facilities, accounts for about 43,000 excess neonatal deaths annually in EAG states. Evidence suggests that low-quality care is among the important causes. Most births in India now occur in facilities. Many happen in private facilities run by providers who lack training, resources, and legal permission. The quality of private health facilities serving the rural EAG population appears to be particularly poor.