'Nobody delivers at home now' : who and why women participate in a conditional cash transfer program to promote institutional delivery in Madhya Pradesh, India

Abstract: Background: One-fifth of global maternal deaths occur in India making this a serious public health challenge. It is well known that skilled birth attendance and access to quality emergency obstetric care reduces maternal mortality. However, up until 2005, efforts by the government at providing access to emergency obstetric care were thwarted by low uptake of facility-based delivery (39% in the same year). A cash incentive program, Janani Suraksha Yojana (JSY) was implemented in 2005 by the central government to increase facility-based births and reduce maternal mortality. It gave money directly to the women upon discharge from a public health facility after childbirth. Subsequently in 2009 an emergency transport model (Janani Express Yojana, JEY) was implemented to support the JSY program and eliminate physical access barriers to giving birth in a facility. Methods: Data for this thesis was collected between January 2011 and April 2015 from three districts (Ujjain, Shahdol and Panna) in the central Indian state of Madhya Pradesh. The thesis is organized into four studies (I-IV). In study I, a structured questionnaire was used to identify predictors of JSY program participation and reasons for non-participation in a population-based sample of 478 women. In study II, qualitative interviews with 24 JSY beneficiaries and non-beneficiaries explored reasons for their participation in the program. In study III, a facility-based study among 1,005 women was used to study predictors of emergency transport use. In study IV, another population-based survey assessed out-of-pocket expenditures (OOPE) among 2,615 women giving birth. Results: Program uptake was high (76%). Women who were uneducated, multiparous or lacked prior knowledge of the JSY program were more likely to deliver at home. Lack of transportation was the main reason for home births at this point in time (study I). The decision of most women to participate in the program reflected a change in social norms towards delivering in a health facility along with individual perceptions of a safe and easy delivery and pressure from an accredited social health activist (ASHA). Many women reported their behavior was influenced by receiving the incentive, but just as many said it did not play a role in their decision to deliver in a facility. Non-participation was often unintentional due to personal circumstances or driven by a perception of poor quality of care in public sector facilities (study II). JEY uptake was greater in women from lower socio-economic backgrounds: rural women were 4.46 times more likely to use JEY (95% CI: 2.38-8.37) compared to urban; and women belonging to scheduled tribes were 1.60 times more likely (95% CI: 1.18-2.16) than women from a general caste. A third of the JEY users experienced a delay in reaching the health facility (study III). The large majority (91%) of women reported OOPE. It was driven largely by indirect costs like informal payments (37%) and food and cloth items for the baby (47%), not direct medical payments (8%). Being a JSY beneficiary increased odds (AOR: 1.58; 95% CI: 1.11- 2.25) of incurring OOPE. However among women who had any OOPE, JSY beneficiaries had a 16% decrease (95% CI: 0.73 - 0.96) in OOPE compared to women who gave birth at home (study IV). Discussion/Conclusion: There was significant program uptake in our study area with a large majority of poor women participating in the program. There are multiple drivers influencing participation: (i) a number of supporting elements (ASHA, cash incentive, transportation support) and (ii) the program does not occur in a vacuum but in a context with dynamic social norms around childbirth. There were limits to the influence of the cash and behaviors may be as much influenced by social norms and social pressures for many. Even though the uptake to the emergency transport service was low, the JEY complemented the JSY program by providing some of the most vulnerable women transport to a health facility and decreasing the geographical barrier. Nevertheless, there are opportunities to expand the service to more women and improve the time it takes to reach the health facility. OOPE is still prevalent among women who deliver under the JSY program. However the cash incentive was large enough to defray the OOPE enabling the poorest women to have a net gain. The program seems to be effective in providing financial protection for the most vulnerable groups (i.e. women from poorer households and disadvantaged castes).