Neonatal Mortality Declined and Antenatal Visits Rose After Initiation of India's Safe Motherhood Program
In a national study of a government program designed to encourage Indian women to give birth at health facilities, the proportion of new mothers who had made three antenatal visits rose from 46% before implementation to 54% several years after program initiation, and the proportion who had given birth in a facility increased from 41% to 54%.1 In addition, the perinatal mortality rate declined from 42 to 37 deaths per 1,000 pregnancies, and the neonatal mortality rate dropped from 34 to 30 deaths per 1,000 live births.
Janani Suraksha Yojana (Safe Motherhood Scheme) was launched by the Indian government in 2005 to reduce the number of perinatal, neonatal and maternal deaths by encouraging women of low socioeconomic status to give birth in a government or accredited private health facility. Under the program, eligible women—those who are having their first or second birth and either live below the poverty line or belong to a scheduled caste or tribe—receive a cash payment (600–700 rupees, equivalent to US$13–16) if they give birth in an appropriate health facility; in 10 high-focus states that have low rates of in-facility births, all women are eligible and the financial incentive is higher (1,000–1,400 rupees). The program has more beneficiaries than any other conditional cash transfer program in the world: During the 2009–2010 financial year, it reached an estimated 9.5 million women, or 36% of the women who gave birth in India.
This study, which is the first full evaluation of the program's impact, used data from household surveys conducted in 2002–2004 and 2007–2009 to examine pregnancy, delivery and birth outcomes; the first study was done prior to implementation of Janani Suraksha Yojana, the second about 2–3 years after program initiation. Both surveys were representative at the district level and focused on women who had given birth in the past 12 months.
The researchers conducted multivariate logistic regression analyses to examine associations between women's demographic and socioeconomic characteristics and participation in the program (i.e., whether they received payments). In addition, they used three analytical approaches—exact matching, with-versus-without comparison and district-level differences in differences—to estimate the program's impact on the probability that women would make at least three antenatal visits, deliver in a health facility or have a skilled attendant at birth, or that they would experience a perinatal death (stillbirth after 28 weeks' gestation or death of a newborn within a week) or neonatal death (within a month of birth). Outcomes were calculated for India as a whole, for the 10 high-focus states, for six remote northeastern states and for all other (nonfocus) states.
Participation in the program was about 9% nationally in 2007–2009, but it varied widely across districts and states; variation was higher between states than between districts within the same state. In four of the 10 high-focus states, participation ranged from 32% (Assam) to 44% (Madhya Pradesh), but it was as low as 7% in others. Nationally, participation was highest among women who had had 1–5 or 6–11 years of schooling (12–13%), were in one of the middle three wealth quintiles (10–12%), belonged to a scheduled caste or tribe (12%) or were having their first or second child (12–14%); participation declined steadily with increasing age (from 16% among 15–19-year-olds to 4% among women aged 40–44), but varied little by residence or distance to a facility.
In the regression analyses for all states and for high-focus states, women in the youngest age-groups (those younger than 30) were more likely than 30–34-year-olds to have received assistance (odds ratios, 1.1–1.9). Other factors associated with program participation were having any education (1.2– 1.5) and being from a scheduled caste or tribe (1.1–1.4); the odds of participation were lower among women of higher parity than among those giving birth for the first time (0.5–0.9), and lower among Muslims than among Hindus (0.8). Urban residence was associated with a reduced likelihood of participation, both nationally and in nonfocus states (0.9 and 0.8, respectively), but with an elevated likelihood in high-focus states (1.1).
Nationally, outcomes improved between the two surveys: The proportion of women who had made three antenatal visits increased from 46% to 54%, the proportion who had given birth in a facility rose from 41% to 54% and the proportion whose delivery had been supervised by a skilled attendant rose from 49% to 59%. Furthermore, the perinatal mortality rate declined from 42 to 37 deaths per 1,000 pregnancies, and the neonatal rate dropped from 34 to 30 deaths per 1,000 live births. After adjustment for background characteristics, the three analytical approaches yielded similar estimates of the program's benefits: For every 10 women who participated, one additional woman would obtain proper antenatal care, an additional four or five women would have an in-facility birth and an additional three or four women would have a skilled attendant at the delivery. Moreover, the exact matching and with-versus-without methods found that participation was associated with reductions in the perinatal mortality rate (by 3.7–4.1 deaths per 1,000 births) and the neonatal mortality rate (by 2.3–2.4 deaths per 1,000 births).
In analyses by state type, the exact matching and with-versus-without analyses found that program participation was associated with greater increases in the probability of having an in-facility delivery or a birth attended by skilled personnel in high-focus states (59–65%) than in northeastern states (32–38%) or nonfocus states (5–8%). However, the reductions in perinatal mortality associated with program participation were greater in nonfocus states (5.0–6.0 deaths per 1,000 pregnancies) than in high-focus states (2.5–2.9 deaths per 1,000).
The researchers note several study limitations, including possible unobserved confounding factors and potential underestimation of the program's impact because some women who gave birth at facilities may have been aware of or been encouraged by the program but failed to receive the financial incentive. Despite these limitations, the authors believe that their analysis demonstrated that Janani Suraksha Yojana increased women's use of in-facility delivery and skilled attendants, and reduced perinatal and neonatal mortality. Furthermore, because "continued independent monitoring and evaluation of progress towards these goals is crucial in the coming years," they call on the Indian government to invest in improved data gathering "that will enable conclusive assessment [of whether Janani Suraksha Yojana] is resulting in a reduction in the numbers of neonatal and maternal deaths."—J. Thomas
1. Lim SS et al., India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation, Lancet, 2010, 375(9730):2009–2023.