THE LANCET: Women Deliver Special Issue Press Release
Cash payments to pregnant women in India to increase births in health facilities reduce both perinatal and neonatal dealths
An Article in this week’s Women Deliver Special Issue of The Lancet assesses India’s Janani Suraksha Yojana (JSY)—a conditional cash transfer programme to increase births in health facilities. As well as increasing rates of antenatal care and births in health facilities, early findings show the programme is reducing both stillbirths and neonatal deaths. The study was carried out jointly by the Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, WA, USA and the Public Health Foundation of India (PHFI), New Delhi, India and was written by Dr Stephen S Lim, Dr Lalit Dandona, Dr Emmanuela Gakidou, and colleagues.
In 2005, the year JSY was launched, more than 78 000 (20%) of 387,200 maternal deaths worldwide, and more than 1 million (31%) of 3.4 million neonatal deaths occurred in India, highlighting the dire need for new interventions.
According to JSY’s guidelines, after delivery in a government or accredited private health facility, eligible women would receive 600 Indian rupees (US$13·3) in urban areas and 700 rupees ($15·6) in rural areas. In ten high-focus states (Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir) with low in-facility birth coverage, all women irrespective of socioeconomic status and parity are eligible for the cash benefit. The cash incentive is higher in these states than in the other states: 1000 rupees ($22·2) in urban areas and 1400 rupees ($31·1) in rural areas. In the non-high-focus states, women were eligible for the cash benefit only for their first two livebirths, and only if they had a government-issued below-the-poverty-line card or if they were from a scheduled (low) caste or tribe.
In this new work, the authors used data from the nationwide district-level household surveys done in 2002–04 and 2007–09 to assess receipt of financial assistance from JSY, and to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. JSY had a significant effect on increasing antenatal care and in-facility births. For every ten women receiving JSY, one additional woman would receive three antenatal care visits and an additional four or five women would give birth in a facility. In two out of three of the analytical approaches, JSY also had a significant effect in reducing perinatal and neonatal deaths. In 2002-04, around 42 perinatal deaths occurred for every 1,000 pregnancies and around 34 neonatal deaths occurred for every 1,000 livebirths at the national-level. For every 1,000 women receiving the cash payment, there would be around 4 fewer perinatal deaths* and around 2 fewer neonatal deaths*. The study showed no effect on maternal mortality, but the authors note that analysis was likely under-powered to detect an effect of JSY.
Women with any level of education had greater odds of receiving JSY payments than those with none; and in high-focus sates, women in the richest 20% had the lowest chances of receiving payments—but it was the women who were in the sixth and seventh deciles who had the best chances of receiving payment, not the poorest 20%.
The authors say: “The finding that the poorest and the least educated women do not consistently have the highest odds of being JSY recipients indicates that an improvement of the targeting of this programme is required…approaches to raise awareness and encourage the poorest and least educated women to take advantage of the JSY benefits need to be investigated and implemented, such as communication strategies that are not dependent on literacy.
They add: “Physical access might be a substantial barrier for women in the lowest socioeconomic status groups since JSY payments can only be made in accredited health facilities. Noteworthy is that Madhya Pradesh, which has made special efforts to accredit remote health facilities, also has one of the highest levels of participation in JSY…cultural barriers against in-facility births are also prevalent among women of low socioeconomic status in India, and these barriers must be addressed. We noted lower uptake by Muslims and Christians than by women of other faiths that might suggest poor reach of accredited social health activists in these communities or poor access of these minorities to accredited health facilities. Finally, the previous national maternity benefit scheme included a payment of 500 rupees ($11) to poor women for deliveries at home. This type of payment continued under the JSY scheme as attempts to exclude this component were met with judicial opposition, but continuation of this payment might be a partial disincentive for giving birth in a health facility.”
They conclude: “Our preliminary evidence shows that the expansion of JSY has led to substantial increases in coverage of antenatal and intrapartum care, and has probably ontributed to reductions in the numbers of perinatal and neonatal deaths.”
In an accompanying Comment, Professor Vinod K Paul, All India Institute of Medical Sciences, New Delhi, India, says: “The JSY is undoubtedly a path-breaking initiative and its full effect and implications have yet to unfold. The challenge is to strengthen, streamline, and deepen its implementation, and as Lim and colleagues have emphatically advocated, to increase its equity quotient and ensure continued independent monitoring and evaluation.”
For Dr Emmanuela Gakidou or Dr Stephen Lim at the Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA or for Dr Lalit Dandona at the Public Health Foundation of India, New Delhi, India, please contact William Heisel, IHME Communications. T) +1 (206) 897-2886 / + 1 (206) 612-0739 E) email@example.com
Professor Vinod K Paul, All India Institute of Medical Sciences, New Delhi, India. T) +91 9811042437 E) firstname.lastname@example.org