Abstract
Not all eligible women use the available services under India's Janani Suraksha Yojana (JSY), which provides cash incentives to encourage pregnant women to use institutional care for childbirth; limited evidence exists on demand-side factors associated with low program uptake. This study explores the views of women and ASHAs (community health workers) on the use of the JSY and institutional delivery care facilities. In-depth qualitative interviews, carried out in September-November 2013, were completed in the local language by trained interviewers with 112 participants consisting of JSY users/non-users and ASHAs in Jharkhand, Madhya Pradesh and Uttar Pradesh. The interaction of impeding and enabling factors on the use of institutional care for delivery was explored. We found that ASHAs' support services (e.g., arrangement of transport, escort to and support at healthcare facilities) and awareness generation of the benefits of institutional healthcare emerged as major enabling factors. The JSY cash incentive played a lesser role as an enabling factor because of higher opportunity costs in the use of healthcare facilities versus home for childbirth. Trust in the skills of traditional birth-attendants and the notion of childbirth as a ‘natural event’ that requires no healthcare were the most prevalent impeding factors. The belief that a healthcare facility would be needed only in cases of birth complications was also highly prevalent. This often resulted in waiting until the last moments of childbirth to seek institutional healthcare, leading to delay/non-availability of transportation services and inability to reach a delivery facility in time. ASHAs opined that interpersonal communication for awareness generation has a greater influence on use of institutional healthcare, and complementary cash incentives further encourage use. Improving health workers' support services focused on marginalized populations along with better public healthcare facilities are likely to promote the uptake of institutional delivery care in resource-poor settings.
Highlights
The Millennium Development Goals (MDGs) expired in 2015, India is still far from achieving MDGs 4 and 5 (Paul, et al, 2011)
We found that ASHAs were responsible for providing most of the basic necessary support services, such as 1) identifying pregnant women in their communities; 2) providing expectant mothers with counsel on maternal and child health (MCH) issues, birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, and contraception; and 3) assisting them in seeking maternal health services, including arranging transport and accompanying them to institutional delivery care facilities
This study found that, overall, the use of maternal healthcare facilities is largely driven by ASHAs' support services rather than the cash incentive component
Summary
The Millennium Development Goals (MDGs) expired in 2015, India is still far from achieving MDGs 4 (reduce child mortality by two-thirds) and 5 (reduce maternal mortality by three-quarters) (Paul, et al, 2011). In low-focus states, the cash incentive is INR 700, and is limited to women below the poverty line, as well as scheduled caste/tribe women (Government of India, 2014a). Those who registered under the JSY but delivered at home are entitled to cash assistance of INR 500 per delivery. Across all states, the JSY provides a transport allowance (INR 300) to eligible expectant mothers who reach healthcare facilities for delivery without the help of ASHA for transport. For expectant mothers reaching facilities with an ASHA's assistance, this amount is provided to the ASHA for arranging the transport (Government of India, 2014c, 2015a). To complement the JSY, the Government of India launched Janani Shishu Suraksha Karyakram (JSSK) on 1st June 2011 with a provision of free transport, diagnostics and drugs to mother and newborn (Government of India, 2015a)
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