Maternal Healthcare Indicators Research Articles

Adverse pregnancy outcome and its association with the various determinants of current pregnancy in a district hospital, urban Bengaluru, India

Background: Maternal health is a crucial aspect of public health, directly influencing pregnancy outcomes. Adverse outcomes, such as miscarriage, stillbirth, cesarean delivery, and abortion, reflect poor maternal health and contribute to maternal mortality and infant mortality rates. Antenatal care (ANC) and institutional delivery are pivotal strategies to mitigate maternal and fetal complications. However, the escalating rates of cesarean sections in India, surpassing the WHO-recommended threshold, present a severe public health challenge. Methods: This retrospective cross-sectional study, conducted in urban Bengaluru from January to July 2023, aimed to identify adverse pregnancy outcomes and their determinants among women aged 15 to 49 in India. Data from maternal birth and labor records were analyzed, encompassing sociodemographic factors, obstetric characteristics, and adverse outcomes. Results: The study revealed a 20.8% magnitude of adverse pregnancy outcomes. It was found to be higher among women in the age group above 30 years, multigravida, have low blood pressure (BP) both systolic and diastolic, B blood group, positive Rh type, a male baby. In bivariate analysis, higher odds were observed among women in the 30-49 age group, body mass index overweight category, active management of the third stage of labor, and delayed cord clamping were found to be statistically significant. Conclusions: The study underscores the urgency for an expanded action plan to enhance maternal healthcare in India. While governmental initiatives exist, there remains a pressing need to address unnecessary caesarean deliveries and associated complications. The findings advocate for heightened awareness, community health worker training, and stringent guidelines on the necessity of caesarean sections.

Temporary childbirth migration and maternal health care in India.

Women in South Asia often return to their natal home during pregnancy, for childbirth, and stay through the postpartum period-potentially impacting access to health care and health outcomes in this important period. However, this phenomenon is understudied (and not even named) in the demographic or health literature, nor do we know how it impacts health. The aim of this study is to measure the magnitude, timing, duration, risk factors and impact on care of this phenomenon, which we name Temporary Childbirth Migration. Using data from 9,033 pregnant and postpartum women collected in 2019 in two large states of India (Madhya Pradesh and Bihar) we achieve these aims using descriptive statistics and logistic regression models, combined with qualitative data from community health workers about this practice. We find that about one third of women return to their natal home at some point in pregnancy or postpartum, mostly clustered close to the time of delivery. Younger, primiparous, and non-Hindu women were more likely to return to their natal home. Women reported that they went to their natal home because they believed that they would receive better care; this was born out by our analysis in Bihar, but not Madhya Pradesh, for prenatal care. Temporary childbirth migration is common, and, contrary to expectations, did not lead to disruptions in care, but rather led to more access to care. We describe a hitherto un-named, underexplored yet common phenomenon that has implications for health care use and potentially health outcomes.

Correlations among the maternal healthcare services in Bangladesh: An application of joint modelling technique

BackgroundCaesarean section (C-section) in Bangladesh have received great attention as the number has been amplified during the last two decades. The question arises whether this rise has a correlation with other maternal healthcare services and/or has been influenced by their predictors. ObjectiveThe main objectives of this study are to assess correlations among the maternal healthcare indicators—antenatal care use, childbirth in private facilities, and childbirth through C-section—and identify their associated predictors in Bangladesh through the development of an appropriate cluster-adjusted joint model that accounts for inter-correlation among the indicators in the same cluster. DesignThe 2019 Bangladesh Multiple Indicator Cluster Survey data have been utilized in this study. Separate generalized linear mixed models developed for the three outcome variables are combined into a joint model by letting cluster-specific random effects be in association. FindingsThe joint model shows that the number of antenatal cares is fairly positively correlated with delivery in private facilities and C-section, while the latter two are strongly positively correlated. Household socio-economic condition, women and their partners' education, women's exposure to mass media, place of residence, religion, and regional settings have significant influence on the joint likelihood of receiving antenatal care, choosing a private health facility for birth, and opting for C-section birth. Key conclusions and implicationsThe rising rate of C-section delivery over time is alarming for Bangladesh to achieve the World Health Organization target of 10–15 %. The joint model reveals that the rising rate of C-sections may be correlated with the choice of a private health facility as the delivery place. The study findings also suggest that maternal childbirth care is private-dominant and predominantly utilized by urban women with better education and higher socio-economic status. The policy should focus on strengthening the public health sector while also keeping importance in increasing coverage of maternal care services among the less well-off.

Empowering Women’s Health: Transforming Maternal Health Care in India

An indicator of the reproductive health of women in an area is the maternal mortality rate. A lot of women in the reproductive age range pass away from difficulties during, during, or related to pregnancy, childbirth, or abortion. Maternal mortality, a critical indicator of a country's healthcare system and women's well-being, has been a persistent concern in India. The study examines the progress and strategies employed in reducing maternal mortality in India. The research explores the initiatives undertaken by the Indian government under the National Health Mission to address maternal health. The findings serve as a valuable resource for policymakers, healthcare professionals, and researchers striving to advance women's sexual and reproductive health rights while reducing maternal mortality globally.
 KEYWORDS: Maternal mortality, Reproductive health, women, India

Exploration of spatial clustering in maternal health continuum of care across districts of India: A geospatial analysis of demographic and health survey data.

The continuum of care (CoC) throughout pregnancy, delivery and post-delivery has recently been highlighted as an integrated intervention programme for maternal, new-born, and child health. Existing literature suggests the importance of continuum of care (CoC) for improved maternal and child health outcomes. However due to unavailability of data at the lowest administrative levels, literature on spatial pattern of uptake of full CoC is lacking. The present study attempts to focus on the spatial analysis of CoC in maternal health care in India. The study is based on the fourth round of National Family Health Survey data conducted in 2015-16 in India. The outcome variable used is maternal health continuum of care which includes- at least 4 ANC visits, delivery through skilled birth attendant and postnatal check-up within 48 hours of delivery. Univariate and bivariate Local Indicator of Spatial Association (LISA) maps have been generated to show the spatial pattern of CoC across 640 districts in India. We also employed spatial regression techniques to explore the determinants of CoC. Percentage of women who followed full CoC was observed to be least for East Kameng (0.0%) district of Arunachal Pradesh and highest in North Goa district (90.4%). Majority of districts where uptake of full CoC was more than 80 percent were found concentrated in southern region on India. Equivalently, findings indicated a strong spatial clustering of full CoC with high-high clusters mostly concentrated in southern districts. Low-low district clusters are concentrated in the states of Uttar Pradesh, Bihar and Madhya Pradesh. For complete CoC the global Moran's I is 0.73 indicating the spatial dependence. The spatial regression analysis suggested that modern contraceptive use, meeting with health worker, urbanization and secondary or above education for women have positive impact on the utilisation of CoC. The spatial pattern indicates district level clustering in uptake of CoC among women. The study suggests policymakers and stakeholders to implement comprehensive interventions at sub-regional levels for ensuring the completion of CoC for women which acts as a preventive measure for adverse outcomes such as-maternal and child mortality.

Rural-Urban Determinants of Receiving Skilled Birth Attendants among Women in Bangladesh: Evidence from National Survey 2017-18.

SBAs (skilled birth attendants) play a crucial role in reducing maternal mortality. The proportion of maternal healthcare in Bangladesh that receives quality care at birth has increased; the reasons for this are unknown. The purpose of this study is to see if there has been a change in the use of specific maternal healthcare indicators in urban and rural areas, as well as significant risk factors. The data set was extracted from a nationally representative survey based on a cross-sectional study, the Bangladesh Health and Demographic Survey (BDHS) 2017-18. The frequency distribution reveals the general state of SBAs. To identify the association, we performed the chi-square test. Finally, multiple logistic regression was used to analyse the factors associated with SBAs and determine the degree of SBAs disparity between urban and rural areas. In Bangladesh, 53% of women received SBAs during childbirth, with urban and rural areas receiving 68.1 and 52.2 percent, respectively. Women with secondary (AOR: 1.79, CI: 1.05-3.08) and higher (AOR: 4.18, CI: 2.09-8.50) education were more likely to receive SBAs than women in urban areas who were illiterate. Husband's education, women's working status, wealth index, children's birth order, and number of ANC visit are significant factors in receiving SBSs in both urban and rural areas. Higher educated husbands are 1.83 times (AOR = 1.83, CI: 1.04-3.25, p = 0.037) and 1.82 times (AOR = 1.82, CI: 1.29-2.59, p = 0.001) more likely to attend skilled births than uneducated husbands in both urban and rural areas. Respondents from the richest families are more likely to attend skilled births than those from the poorest families in both urban and rural areas. During delivery, significant risk factors are substantially related to SBAs. More attention must be given to rural and illiterate populations, who are less likely to obtain these services, to minimize maternal and neonatal mortality. Special programs could be developed to raise awareness and facilitate the poor in receiving the basic necessities of maternal care.

Determinants Of Maternal Mortality: An Empirical Study of Indian States Based on The Random Effect Model Analysis

Background: Healthcare for mothers and children is a significant indicator of a country's well-being. India is one of the nations that were experiencing a rather slow improvement in maternal and child health. Aims: The objective of this study is to analyse the changes in maternal healthcare in India from 2010-11 in health inputs like health infrastructure and government expenditure, health outcomes like antenatal care, postnatal care, institutional delivery, and health impact like Maternal Mortality Ratio (MMR). Methodology: The study is based on secondary data. It employs Average Increasing Rate (AIR) and Average Reduction Rate (ARR), as well as a panel data random effect model, on key health indicators for Indian states. Results: Empirical results say MMR has a statistically significant inverse relationship with female literacy, Per capita Net State Domestic Product (PNSDP), and institutional delivery. The study concludes that after the introduction of NRHM and its constituent elements like JSY and JSSK, government expenditure on health, infrastructure, the percentage of antenatal care, post-natal care, and institutional delivery increased in most of the Indian states, thus helping to increase the pace of the reduction of MMR. However, state performance varies greatly. Conclusions: Policy alone will not provide the desired results; it is also critical to focus on education, particularly female literacy, and economic empowerment. We can make a difference in the health sector if these come together.

Knowledge of pregnancy complications and utilization of antenatal care services in Rwanda.

While Rwanda's progress towards achieving the maternal health care targets of the Sustainable Development Goals is impressive, evidence of women's limited utilization of antenatal care (ANC) services in the context of an improved health care system provides an opportunity for exploring other essential but less highlighted factors that may shape ANC service utilization. In this study, we examined the association between women's knowledge of pregnancy complications and the utilization of maternal health services. We employed logistic regression analysis using the 2015 Rwanda Demographic and Health Survey data. Our analytical sample consisted of women (n=5883) in their reproductive ages (15-49years). Three maternal health care indicators, namely, timing of first ANC visit, number of ANC visits, and place of delivery, were explored. We controlled for the effects of socioeconomic and demographic characteristics, including marital status, place of residence and age. The results show that women with no knowledge of pregnancy complications were less likely to utilize ANC services within the first trimester (odds ratio [OR]=0.76, p<0.01), achieve the WHO recommended minimum of eight visits (OR=0.66, p<0.01), and deliver at a health facility (OR=0.77, p<0.10). Given these findings, we recommend restructuring existing maternal health care programs to include rigorous maternal health education.

A hierarchical capacitated facility location-allocation model for planning maternal healthcare facilities in India

The present work on maternal healthcare in India is motivated by its current status emerging out of limited availability and accessibility of related facilities. Planning for the required maternal healthcare facilities, from basic ones to neonatal ones, is a tedious task from the financial perspectives of both users and the government. This problem has been addressed by proposing a mixed-integer linear programming formulation for determining the optimal number and location of these capacitated and varied facilities and also for the allocation of mothers-to-be to these facilities while minimizing the overall cost. Suitable additional valid inequalities are proposed to be incorporated into the NP-hard model for reducing the computational burden. For further computational advantage, a sequential approach is also proposed. Comparative performance of the proposed approaches has been analyzed using several problems with wide variation in the problem parameters’ values. The sequential approach is found to be very effective and computationally efficient. The results of the sensitivity analyses with respect to coverage distance, capacity, referral proportion and fixed cost provide important and practical insights related to the mix of the facilities to be established. The application of the model for a district in India proves the suitability of the model in the Indian context.

Universal thyroid screening in maternal health care in India: The need of the hour

Universal thyroid screening in maternal health care in India: The need of the hour

Women's autonomy and utilization of maternal healthcare in India: Evidence from a recent national survey.

ObjectiveThe present study aims to examine the association between women’s decision-making autonomy and utilization of maternal healthcare services among the currently married women in India.MethodsA total of 32,698 currently married women aged 15–49 years who had at least one live birth in the past five years preceding the survey and had information regarding autonomy collected by the National Family Health Survey 2015–16 were used for analysis. Bivariate and multivariate logistic regression models were employed for the analyses of this study.ResultsUtilization of maternal healthcare services was higher among the women having a high level of decision-making autonomy compared to those who had a low autonomy in the household. The regression results indicate that women’s autonomy was significantly associated with increased odds of maternal healthcare services in India. Women with high autonomy had 37% and 33% greater likelihood of receiving ANC (AOR: 1.37, 95% CI: 1.25–1.50) and PNC care (AOR: 1.33, 95% CI: 1.24–1.42) respectively compared to women having low autonomy. However, no significant association was observed between women’s autonomy and institutional delivery in the adjusted analysis.ConclusionThis study recommends the need for comprehensive strategies involving improvement of women’s autonomy along with expansion of education, awareness generation regarding the importance of maternity care, and enhancing public health infrastructure to ensure higher utilization of maternal healthcare services that would eventually reduce maternal mortality.

Continuum of maternal health care services and its impact on child immunization in India: an application of the propensity score matching approach.

Continuum of care throughout pregnancy, delivery and post-delivery has proved to be a critical health intervention for improving the health of mothers and their newborn children. Using data from the fourth wave of the National Family Health Survey (NFHS-4) conducted in 2015-16, this study examined the correlates of utilization of maternal health care services and child immunization following the continuum of care approach in India. The study also assessed whether the continuity in utilizing maternal health care services affects the immunization of children. A total of 33,422 survey women aged 15-49 were included in the analysis of maternal health care indicators, and 8246 children aged 12-23 months for the analysis of child immunization. The results indicated that about 19% of the women had completed the maternal health continuum, i.e. received full antenatal care, had an institutional delivery and received postnatal care. Women with a higher level of education and of higher economic status were more likely to have complete continuum of care. Continuity of maternal health care was found to be associated with an increase in the immunization level of children. It was observed that 76% of the children whose mothers had complete continuum of care were fully immunized. Furthermore, the results from propensity score matching revealed that if mothers received continuum of care, the chance of their child being fully immunized increased by 17 percentage points. The results suggest that promotion of the continuum of maternal health care approach could help reduce not only the burden of maternal deaths in India, but also that of child deaths by increasing the immunization level of children.

Maternal health care in India: A reflection of 10 years of National Health Mission on the Indian maternal health scenario

ObjectiveMaternal healthcare coverage is the outcome of health service availability and utilization, and includes antenatal care (ANC), care at delivery, and postnatal care. This study examines the contribution of India’s National Health Mission (NHM) to maternal health through a pre–post comparison of rates of delivery at a healthcare institution and use of ANC along with inequalities in the determinants of one of the major maternal health outcomes—at least four ANC visits. MethodsData came from the Indian National Family Health Surveys conducted between 1992–93 and 2015–16. A multivariate logistic regression model was used to estimate the odds ratios (ORs) associated with the predictors of at least four ANC visits. ResultsInstitutional delivery increased by 12.6 percentage points between 1992–93 and 2005–06 (the pre-NRHM era), and thereafter interventions through the National Rural Health Mission/NHM contributed to a significant increase of 40.2 percentage points from 2005–06 to 2015–16. However, both inter- and intra-state disparities persist even now. Overall, the proportion of pregnant women who have at least four ANC visits is as low as 51.2 percent. The likelihood of having at least four ANC visits is almost four times higher for women in the richest households compared with those in the poorest (OR: 3.59; 95% CI: 3.44–3.75) ConclusionFuture public health efforts should focus on removing inter- and intra-state disparities in institutional delivery and ensuring at least four ANC visits for pregnant women, to meet the infant and maternal mortality targets set out in the Sustainable Development Goals (SDG).

Catastrophic Health Care Expenditure on Maternal Health Care in India: Evidence from National Level Data

Introduction: Catastrophic health expenditure is defined as payments for health services exceeding 40% ofhousehold disposable income after subsistence needs are met. Utilization of maternal health care serviceshas been recognized as a significant factor in influencing maternal and child mortality. India continuesto account for a quarter of all maternal and child deaths at the world level. The cost of health care iscomparatively higher in private sector than the public health facilities. Households using private inpatientservices are more likely to face catastrophic expenditure.Materials and Method: This paper has utilized the data collected by the National Sample SurveyOrganization (NSSO) during January-June, 2014. It is a cross sectional dataset available in public domain.The dataset provides information on Social Consumption and Health scenario of the population. To carry outthe research, descriptive statistics, bivariate and logistic regression analysis has been used.FINDINGSThe study shows that urban sector, primary educated and women belonging to poorest wealth quintilebear high catastrophic health expenditure than their other counterparts. Western and Southern region havelow percentage of women going for catastrophic expenditure on maternal health care. The likelihood ofcatastrophic health expenditure on maternal health care decreases with the increase in wealth quintile frompoorest to richest.Conclusion: Place of residence, educational status and wealth index plays an important role in determiningthe catastrophic health expenditure on maternal health care. Further research needs to be done in exploringthe factors that leads to inequity of the expenditure used in the utilization of maternal health care.

Socio-economic Determinants in the Utilization of Maternal Health Care in India: Exploring National Level Data

Socio-economic Determinants in the Utilization of Maternal Health Care in India: Exploring National Level Data

Does Public Health Insurance Increase Maternal Health Care Utilization in Egypt?

AbstractThis paper assesses the impact of the national health insurance on the utilization of maternal health care services in Egypt using propensity score matching. The results suggest that health insurance has a strong and robust positive impact on most of the maternal health care indicators. © 2019 John Wiley &amp; Sons, Ltd.

Death of preceding child and maternal healthcare services utilisation in Nigeria: investigation using lagged logit models

BackgroundOne of the factors responsible for high level of childhood mortality in Nigeria is poor utilization of maternal healthcare (MHC) services. Another important perspective which has been rarely explored is the influence of childhood death on MHC service utilization. In this study, we examined the relationship between death of preceding child and MHC services utilization [antenatal care (ANC), skilled attendant at birth (SAB), and postnatal care (PNC)] among Nigerian women and across the six geo-political zones of the country.MethodologyWe analyzed reproductive history dataset for 16,747 index births extracted from the 2013 Nigeria Demographic and Health Survey. The main explanatory variable was survival status of preceding child; therefore, only second or higher order births were considered. Analysis involved the use of descriptive statistics and lagged logit models fitted for each measure of MHC utilization. Association and statistical significance were expressed as adjusted odds ratio (AOR) with 95% confidence interval.ResultsThe use of MCH services for most recent births in the 2013 Nigeria DHS were ANC (56.0%), SAB (34.7%), and PNC (27.3%). Univariate models revealed that the death of preceding child was associated with lesser likelihood of ANC (OR = 0.64, CI 0.57–0.71), SAB (OR = 0.56, CI 0.50–0.63), and PNC (OR = 0.65, CI 0.55–0.69). Following adjustment for maternal socio-economic and bio-demographic variables, statistical significance in the relationship disappeared for the three MHC indicators: ANC (AOR = 1.00, CI 0.88–1.14), SAB (AOR = 0.97, CI 0.81–1.15), and PNC (AOR = 0.95, CI 0.83–1.11). There were no significant variations across the six geo-political regions in Nigeria. The likelihood of ANC utilization was higher when the preceding child died in Northcentral (AOR = 1.19, CI 0.84–1.70), Northeast (AOR = 1.26, CI 0.99–1.59), and South-south (AOR = 1.19, CI 0.72–1.99) regions while the reverse is the case in Southeast (AOR = 0.39, CI 0.23–0.60). For the Southeast, similar result was obtained for ANC, SAB, and PNC.ConclusionDeath of a preceding child does not predict MHC services use in Nigeria especially when maternal socio-economic characteristics are controlled. Variations across the Northern and Southern regions did not attain statistical significance. Interventions are needed to reverse the pattern such that greater MHC utilization is recorded among women who have experienced child death.

Inequalities in maternal health care utilization in Benin: a population based cross-sectional study

BackgroundEnsuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes.MethodsThis paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15–49 years in 2006 and 2012 respectively. Women’s characteristics were reported in percentage, mean and standard deviation.ResultsMean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13–1.52), 1.69 (OR = 1.69; 95% CI = 1.20–2.37) and 1.38 (OR = 1.38; 95% CI = 1.16–1.65) times as likely to utilize maternal health care services after adjusting for other covariates.ConclusionThe findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage.

Has the Janani Suraksha Yojana (a conditional maternity benefit transfer scheme) succeeded in reducing the economic burden of maternity in rural India? Evidence from the Varanasi district of Uttar Pradesh.

BackgroundOne of the constraints in the utilisation of maternal healthcare in India is the out-of-pocket expenditure. To improve the utilisation and to reduce the out-of-pocket expenditure, India launched a cash incentive scheme, Janani Suraksha Yojana (JSY), which provides monetary incentive to the mothers delivering in public facility. However, no study has yet examined the extent to which the JSY payments reduce the maternal healthcare induced catastrophic out-of-pocket expenditure burden of the households. This paper therefore attempts to examine the extent to which the JSY reduces the catastrophic expenditure estimate household expenditure on maternity, i.e., all direct and indirect expenditure.Materials and methodsThe study used data on 396 mothers collected through a primary survey conducted in the rural areas of the Varanasi district of Uttar Pradesh state in 2013-2014. The degree and variation in the catastrophic impact of households’ maternity spending was computed as share of out-of-pocket payment in total household income in relation to specific thresholds, across socioeconomic categories. Logistic regression was used to understand the determinants of catastrophic expenditure and whether the JSY has any role in influencing the expenditure pattern.ResultsResults revealed that the JSY beneficiaries on an average spent about 8.3% of their Annual Household Consumption Expenditure on maternity care. The JSY reimbursement could reduce this share only by 2.1%. The study found that the expenditure on antenatal and postnatal care made up a significant part of the direct medical expenditure on maternity among the JSY beneficiaries. The indirect or non-medical expenditure was about four times higher than the direct expenditure on maternity services. The out-of-pocket expenditure across income quintiles was found to be regressive i.e. the poor paid a greater proportion of their income towards maternity care than the rich. Results also showed that the JSY reimbursement helped only about 8% households to escape from suffering catastrophic burden due to maternity payments.ConclusionsIt can be concluded that the JSY appeared to have achieved only a limited success in reducing the economic burden due to maternity. To reduce the catastrophic burden, policy makers should consider increasing the JSY reimbursement to cover not only antenatal and postnatal services but also non-medical expenditure due to maternity. The government should also take appropriate measures to curb non-medical or indirect expenditure in public health facilities.Significance for public healthImproving the well-being of mothers is an important public health goal for India. For improving maternal health, it is necessary that mothers utilize maternity services. However, maternity often becomes an economic burden, especially for disadvantaged and poorer groups of the society. To encourage mothers to utilize services, India launched a conditional maternity benefit transfer scheme back in 2005. This study explored whether the scheme has been able to help alleviate the burden of maternity expenditure or not. The study finds that the scheme has been successful only partially to reduce outof- pocket expenditure suggesting that maternity is a costly affair in rural India. Since the scheme is unable to save mothers from catastrophic expenditures, it is also unable to save mothers from a wide ranges of health illeffects caused by catastrophic expenditure.

Amplifying accountability by benchmarking results at district and national levels

AbstractThis multi‐level ethnography of the Zambian health system illustrates the importance of top‐down accountability, and how it has emerged in a historically neglected sector. Maternal healthcare indicators are prioritized when they are benchmarked, at district and national levels. The realization that Zambia was lagging behind African countries in making progress towards Millennium Development Goal (MDG) 5 (to reduce the maternal mortality ratio by three quarters) appears to have evoked reputational concerns and revealed inspirational possibilities. Growing prioritization also stems from a change in incentives, with some partner funding being conditional on the proportion of deliveries attended by skilled health personnel.