Over 15 years of incentivised institutional delivery: Has it ensured safe births?

The share of India's institutional deliveries increased to 88.6 per cent in 2019-2021 (National Family Health Survey 5) from 40.8 per cent in 2005-06 (NHFS 3).

The nine targeted states — Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Rajasthan, Jharkhand, Odisha, Chhattisgarh and Assam — recorded a similar uptick during the period, ranging from 50-64 percentage points. Madhya Pradesh led the way with a 64.5 percentage point growth. These states account for nearly half of India’s population, over 60 per cent of maternal deaths, 70 per cent of infant deaths and 12 per cent of global maternal deaths.  

Usha Ram, professor, International Institute of Population Science, said:

In the early 2000s, institutional deliveries were very low in India, mainly because access to the services was limited. With the launch of the National Health Mission and schemes like Janani Suraksha Yojana (JSY), the indicator has improved considerably.

Institutional deliveries were first incentivised by the central government in 2005 with JSY, under which a direct cash transfer is promised if a woman delived a baby at a medical facility, rather than at home. Annual JSY beneficiaries have shot up to over 10 million from 739,000 in 2005-06, according to the 2020-2021 annual report of the Union health ministry.

Expenditure under the scheme has seen a similar trend, up from Rs 38 crore in financial year 2005-06 to Rs 1,773.88 crore in 2019-20. In 2020-21 (up to September 2020), the expenditure reported was Rs 703.64 crore (provisional), the report showed.

The Janani Shishu Suraksha Karyakram (JSSK), built on the success of JSY, was launched in June 2011. It entitled pregnant women to several benefits, including no-expense childbirth, free transport from home to medical facility, drugs, diet during stay, diagnostics and blood transfusion. In 2013, the cost of treating “complications during ante-natal and postnatal period and sick infants up to one year of age” was also brought within the ambit of the scheme. 

In 2020-21, nearly 17 per cent pregnant women received free medicines, 19 per cent received free diagnostics, 19 per cent received free food, 7 per cent received free transport (home to the facility and drop back) under this scheme, according to data from the Health Management Information System.

The Pradhan Mantri Surakshit Matritva Abhiyan, launched in June 2016, was aimed at providing free, assured and quality antenatal care. As of January 5, 2021, more than 20.6 million antenatal care check-ups were conducted by over 6,000 volunteers in over 17,000 government facilities. 

Similar incentive-driven schemes at a state-level that promote institutional births include Shramik Seva Prasuti Sahayata Yojana in Madhya Pradesh, Janani Suvidha Yojana in Haryana, Ayushmati Scheme in West Bengal, Chiranjeevi Yojana in Assam and Gujarat and Mamta Friendly Hospital Scheme in Delhi. 

Indicators haven't kept pace

Maternal mortality ratio (MMR), infant mortality rate and neonatal mortality rate (NMR), however, have not improved at the same pace as institutional births. The nine focus states continue to have the highest MMR, a majority of which are well beyond India’s national average of 103. The Sample Registration System report by the Registrar General of India for 2017-19 showed: 

Bihar — 130

UP — 167

MP — 163

Uttarakhand — 101

Rajasthan — 141

Jharkhand — 61

Chhattisgarh — 160

Odisha — 136

Assam — 205 

Healthcare delivery and service utilisation are very different in two groups of India’s states — those performing better than the national average and those lagging behind. The country as a whole may be able to meet the United Nations-mandated Sustainable Development Goal of reducing MMR to 70 by 2030, but the lagging states will continue to perform poorly unless given an impetus, Ram said.  

Policies that recognise and monitor the subnational disparities, particularly in the Empowered Action Group States plus Assam, and the rural and tribal areas are needed, according to a 2021 report published in the International Journal of Obstetrics and Gynaecology that Ram co-authored.

Except Assam, the states recorded a higher NMR in private institutions than home births. The five other focus states recorded a difference of under 17 deaths per 1,000 births. 

“Despite increase in delivery facilities, neonatal and infant mortality rates remain high in these settings,” the study noted in conclusion. 

The lesson

Schemes incentivising institutional delivery are not enough to ensure a safe birth. A holistic approach is needed to address infrastructure and human resource shortcomings. 

“An infrastructure development plan focused on the actual patterns of use could close the remaining gaps in a very short time,” noted a September 2011 evaluation of JSY by the Union health ministry. Independent research on maternal and neonatal health led to similar observations.  

The workforce involved in delivery of the various government schemes need to be strengthened to bring about a noticeable change, said Ram. “Accredited Social Health Activists (ASHA) and Auxiliary nurse midwives are the backbone of the government schemes but are severely burdened.”

The eligibility criteria for such schemes needs to be expanded, because currently it excludes those who actually need it, said Sanghita Bhattacharyya, senior public health specialist at the Public Health Foundation of India. Some schemes are applicable only if the mother is 19 years of age or above, some are only for the first child and some require ‘below poverty line’ identification, she added. “An 18-year-old pregnant woman living below the poverty line is most vulnerable but would not make the cut for several schemes.”

An ideal institutional delivery needs to be defined for better monitoring of the scheme outcomes, said Dileep Mavalankar, director, Indian Institute of Public Health, Gandhinagar believes that we need to monitor outcomes to understand how successful the scheme really is. 

“We can have a 10-point checklist, with indicators such as how soon the pregnant woman is checked by the midwife, was the pulse / heartbeat of the baby recorded, proper steps of infection control and 5-6 immediate steps for baby’s survival,” he suggested. 

India must also close the data gap, the expert said. “Each institution must publish their morbidity and mortality data regularly.” Health centres must also be incentivised to deal with such a high load, he suggested.