Same Average, Different Odds: Maternal-health Lessons for India from Rwanda and Peru.

Background: India has reduced its maternal mortality ratio faster than the global average, reaching 93 per 100,000 live births in 2019-21 and 88 in 2021-23. The national figure hides a nearly nine-fold gap between the best and worst-performing states. Deaths that remain fall mainly on rural, tribal, and poor women, in whom the three classic delays in obtaining care overlap with poverty, distance, caste, and gender. Policy and implications: The most useful lessons for India come not from wealthy systems but from countries that started poorer and still moved faster on equity. Rwanda combined a village health-worker cadre, near-universal community-based insurance, performance-based financing, and maternal death audits, working on the cost barrier and the second and third delays at once. Peru marginalized Andean and Amazonian women through free insurance, maternal waiting homes, and culturally adapted childbirth, working on first and second delays. Peru also shows that progress can be reversed and that judging a program only by its targets can erode the care it is meant to deliver. Recommendations: India should hold leadership of the gap between states rather than the national average, take the cost of delivery and its complications off poor families, fund respectful and culturally appropriate care alongside facility expansion, pay for audited quality, and track women's experience of care, not coverage alone. Conclusions: India has shown that it can move its national numbers. The harder task is distributional: giving a woman in Assam or tribal Madhya Pradesh the odds of being a woman in Kerala. Rwanda and Peru suggested that this is within reach without a high-income budget, provided that the system is rebuilt around financial protection, a trusted community workforce, audited quality, and genuine respect for women.