Abstract
BackgroundIndia leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world’s largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women’s access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women’s use of maternal health services in Gujarat and Tamil Nadu.MethodsUsing the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section.ResultsTamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women’s education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands’ education predicted institutional delivery in Gujarat.ConclusionsOverall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.
Highlights
The overall framework for Janani Suraksha Yojana (JSY) is similar throughout India, but states have different eligibility criteria and incentives based on their institutional birth data when the scheme was created [4]
Data collection District Level Household Survey (DLHS)-3 (2007–08) data were collected by the International Institute for Population Sciences (IIPS), Mumbai, on behalf of the Indian Government’s Ministry of Health and Family Welfare [21]
There was no significant association between Chiranjeevi Yojana (CY)/JSY and C-section in Gujarat
Summary
India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world’s largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women’s access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women’s use of maternal health services in Gujarat and Tamil Nadu. In 2005–06, the nation launched the world’s largest conditional cash transfer scheme for maternal health, Janani Suraksha Yojana (JSY), or a “scheme to protect mothers.”. In states with high maternal mortality and low institutional deliveries (low performing states), women receive cash incentives for institutional births in public or accredited health facilities regardless of socioeconomic status, age, or parity. In states with better maternal and institutional delivery data (high performing states), cash incentives are limited to the first two live births of women below the poverty line (BPL) and from scheduled castes and tribes [4]
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