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India's conditional cash transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality?
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, R. D. Gardi Medical College, Ujjain, India.
Department of Public Health, R. D. Gardi Medical College, Ujjain, India.
Department of Public Health, R. D. Gardi Medical College, Ujjain, India and Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm.
2013 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 6, e67452Article in journal (Refereed) Published
Abstract [en]

Background: India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR. Method: Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above-mentioned nine states were analysed to assess relationship between MMR and institutional births. Results: Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = 20.11). The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68]. Conclusions: Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

Place, publisher, year, edition, pages
Public Library of Science , 2013. Vol. 8, no 6, e67452
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-79613DOI: 10.1371/journal.pone.0067452ISI: 000321150000081OAI: oai:DiVA.org:umu-79613DiVA: diva2:655712
Available from: 2013-10-13 Created: 2013-08-26 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India
Open this publication in new window or tab >>Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: To accelerate the coverage of skilled birth attendance, in 2005, the Indian government initiated a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY) that provides cash to women upon delivering in health facilities. The attempt to increase the utilization of facilities through the JSY, given the health system’s fragile state, has raised concerns about the programme’s success at achieving its intended goal of reducing maternal mortality ratio (MMR).

Aim: To understand the implementation of the CCT policy to promote institutional births in India, with a special focus on nine of India’s poorer states.

Methods: Thesis uses both quantitative and qualitative methods. The changes in coverage and inequalities in institutional births in the nine states following the initiation of JSY were analysed by comparing levels before and during the programme using state and district level data. The association between the coverage of institutional births and MMR was assessed using regression analysis (I). The change in socioeconomic inequalities in institutional births was estimated using the concentration index and concentration curve, and contributions of different factors to inequalities was computed by decomposition analysis (II). The quality of referral services was studied by conducting a survey of health facilities (n=96) and post-partum women (n=1182) in three districts of Madhya Pradesh. Conditional logistic regression was used to study the association between maternal referrals and adverse birth outcomes, while spatial data for referrals were analysed using Geographical Information Systems (III). Semi-structured interviews were conducted with government and non-government stakeholders (n=11) to explore their perceptions of the JSY, and the data were analysed using a thematic framework approach (IV).

Results: In five years, institutional births increased significantly from a pre-programme average of 20% to 49%. However, no significant association between district-level institutional birth proportions and MMR was found (I). The inequality in access to institutional delivery care, although reduced since the introduction of JSY, still persists. Differences in male literacy, availability of emergency obstetric care (EmOC) in public facilities and poverty explained 69% of the observed inequality. While MMR has decreased in all areas since the introduction of JSY, it has declined four times faster in the richest areas than in the poorest (II). Adjusted odds for adverse birth outcomes among those referred were twice than in those who were not referred (AOR 2.6, 95% CI 1.1-6.6). A spatial analysis of the inter-facility transfer time indicated that maternal deaths occurred despite good geographic access to EmOC facilities (III). While most health officials considered stimulus in the form of JSY money to be essential to promote institutional births, non-government stakeholders criticised JSY as an easy way of addressing basic developmental issues and emphasised the need for improvements to health services, instead. Supply-side constraints and poor care quality were cited as key challenges to programme success, also several implementation challenges were cited (IV).

Conclusions: Although there was a sharp increase in coverage and a decline in institutional delivery care inequalities following the introduction of JSY, the availability of critical care is still poor. CCT programmes to increase service utilization need to be essentially supported by the provision of quality health care services, in order to achieve their intended impacts on health outcomes.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2015. 85 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1770
Keyword
Maternal health, Condititonal cash transfer, Inequality, Referral, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-112844 (URN)978-91-7601-393-9 (ISBN)
Public defence
2016-01-15, Sal 135, Allmänmedicin, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2015-12-18 Created: 2015-12-16 Last updated: 2015-12-17Bibliographically approved

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