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

News: Maternal mortality ratio (MMR), infant mortality rate and neonatal mortality rate (NMR) have not improved at the same pace as institutional births.

About the growth in institutional births

The share of India’s institutional deliveries increased to 88.6% in 2019-2021 (National Family Health Survey 5) from 40.8% in 2005-06 (NHFS 3). The nine targeted states — Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Rajasthan, Jharkhand, Odisha, Chhattisgarh and Assam — recorded a similar increase.

How did the government incentivise institutional deliveries?

Janani Suraksha Yojana (JSY), 2005: Institutional deliveries were first incentivised by JSY. Under this, direct cash transfer is promised if a woman delivered a baby at a medical facility, rather than at home.

According to the 2020-2021 annual report of the Union health ministry, annual JSY beneficiaries have shot up to over 10 million from 739,000 in 2005-06.

Janani Shishu Suraksha Karyakram (JSSK), 2011: It entitled pregnant women to several benefits, including no-expense childbirth, covering the complications during the ante-natal and postnatal period, free transport from home to the medical facility, etc.

According to the Health Management Information System, In 2020-21, nearly 17% of pregnant women received free medicines, 19% received free diagnostics, 19% received free food, 7% received free transport under the scheme.

Pradhan Mantri Surakshit Matritva Abhiyan, 2016: The scheme is providing free, assured and quality antenatal care. As of January 5, 2021, more than 20.6 million antenatal care check-ups were conducted under the scheme.

Similar incentive-driven schemes are being implemented at the state level also. For instance, Ayushmati Scheme in West Bengal, Chiranjeevi Yojana in Assam and Gujarat and Mamta Friendly Hospital Scheme in Delhi, etc.

About the mortality ratio

Maternal mortality ratio (MMR), infant mortality rate and neonatal mortality rate (NMR) have not improved as compared to the Institutional deliveries. The nine focus states continue to have the highest MMR, a majority of which are well beyond India’s national average of 103.

With the present pace, the country as a whole may be able to meet the United Nations-mandated Sustainable Development Goal of reducing MMR to 70 by 2030.

What is the reason behind the low improvement in Mortality rates?

1) Healthcare delivery and service utilisation are very different between states, those performing better than the national average and those lagging behind, 2) Schemes incentivising institutional delivery are not enough to ensure a safe birth, 3) Except Assam, the states recorded a higher NMR in private institutions than home births, 4) Limited beneficiaries: 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.

What should be done to reduce the mortality rates?

1) A holistic approach is needed to address infrastructure and human resource shortcomings, 2) 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, 3) An infrastructure development plan focused on the actual patterns of use could close the remaining gaps between states in a very short time,

4) The eligibility criteria for such schemes need to be expanded because currently, it excludes those who actually need it, 5) An ideal institutional delivery needs to be defined for better monitoring of the scheme outcomes. For instance, creating 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 was recorded, etc., 6) Closing the data gap: Each institution must publish their morbidity and mortality data regularly and Health centres must be incentivised to deal with high loads of cases.

Source: This post is based on the article “Over 15 years of incentivised institutional delivery: Has it ensured safe births?” published in Down To Earth on 25th March 2022.