Cash transfer programme increases child births at facilities, but fails to reduce maternal deaths

To reduce maternal and neo-natal deaths, India launched a cash transfer programme in 2005 that provides monetary incentives for women to give birth in health facilities instead of at home. While the programme successfully increased the use of health facilities for child birth, it did not reduce maternal deaths as much, especially in poor areas. This is according to a doctoral dissertation published at Umeå University.

Doctoral student Bharat Randive at the Department of Public Health and Clinical Medicine found that the so called Janani Suraksha Yojana (JSY) programme successfully increased births at facilities, but due to its implementation in a fragile health system context, it was less effective at reducing fatalities.

"The cash transfer programmes are by themselves inadequate to improve health outcomes," says Bharat Randive. "While the programme can improve service utilisation, it will not reduce maternal and neo-natal deaths unless the socioeconomic inequalities in access to facility-based care are also addressed and the care is of good quality. Emergency obstetric care, which is essential to save lives of pregnant women and babies, is grossly unavailable at public facilities in the poor states of India that form a global hotspot for avoidable maternal deaths."

In his research, Bharat Randive looked at nine Indian states and compared access to care and health outcomes in rich and poor areas. The poor areas of these nine less developed states had 135 more maternal deaths for every 100,000 births and the decline in maternal deaths during the programme in these areas was four times slower than in the rich areas.

As all facilities in the JSY programme are not equipped to provide higher level care, obstetric referral services, which are expected to be saving lives of women and newborns, are important for JSY success. However the findings indicate poor quality of referral services. The referrals were associated with higher chances of adverse outcomes at birth and there were a high number of deaths even when women were referred from facilities within the desired two-hour transfer time. At its implementation, key government officials and non-government stakeholders were critical of the appropriateness of the cash transfer programme and highlighted the importance of strong health systems and good quality services for the programme to succeed at reducing mortality.