|Year : 2012 | Volume
| Issue : 1 | Page : 69-72
Are institutional deliveries promoted by Janani Suraksha Yojana in a district of West Bengal, India?
Tanmay Kanti Panja1, Dipta Kanti Mukhopadhyay2, Nirmalya Sinha3, Asit Baran Saren4, Apurba Sinhababu5, Akhil Bandhu Biswas6
1 Associate Professor, Department of Community Medicine, Midnapur Medical College, Paschim Medinipur, India
2 Assistant Professor, Department of Community Medicine, B.S. Medical College, Bankura, India
3 Assistant Professor, Department of Community Medicine, Midnapur Medical College, Paschim Medinipur, India
4 Associate Professor, Department of Community Medicine, B.S. Medical College, Bankura, India
5 Professor, Department of Community Medicine, B.S. Medical College, Bankura, India
6 Director, Institute of Health and Family Welfare, Kolkata, India
|Date of Web Publication||6-Jun-2012|
Dipta Kanti Mukhopadhyay
Assistant Professor, Department of Community Medicine, B.S. Medical College, Lokepur, Near N.C.C. Office, Bankura - 722 102
| Abstract|| |
'Janani Suraksha Yojana (JSY)' was implemented in India to promote institutional deliveries among the poorer section of the society. A cross-sectional study was conducted in Bankura district among 324 women who delivered in last 12 months selected through 40 cluster technique to find out institutional delivery rate, utilization of JSY during antenatal period and relation between cash benefit under JSY during antenatal period and institutional delivery. Overall institutional delivery rate was 73.1% and utilization of JSY among eligible women was 50.5%. Institutional delivery (84.0%), consumption of 100 iron-folic acid tablets (46.0%) and three or more antenatal check-ups (91.0%) were better in women who received financial assistance from JSY during antenatal period than other women. After adjustment for socio-demographic factors, JSY utilization came out to be significantly (P=0.031) associated with institutional deliveries. The study showed that cash incentive under JSY in antenatal period had positive association on institutional deliveries.
Keywords: Antenatal care, India, Institutional delivery, Janani Suraksha Yojana
|How to cite this article:|
Panja TK, Mukhopadhyay DK, Sinha N, Saren AB, Sinhababu A, Biswas AB. Are institutional deliveries promoted by Janani Suraksha Yojana in a district of West Bengal, India?. Indian J Public Health 2012;56:69-72
|How to cite this URL:|
Panja TK, Mukhopadhyay DK, Sinha N, Saren AB, Sinhababu A, Biswas AB. Are institutional deliveries promoted by Janani Suraksha Yojana in a district of West Bengal, India?. Indian J Public Health [serial online] 2012 [cited 2014 Apr 24];56:69-72. Available from: http://www.ijph.in/text.asp?2012/56/1/69/96980
Conditional cash transfer (CCT) is a new type of social assistance program specifically designed for empowering poor households to avail preventive health services.  Money is a powerful incentive to change behaviors.  This concept is used in CCTs to raise the health service utilization in many countries across the globe, particularly where the indicators were low to start with. 
India's CCT scheme to promote institutional deliveries, the 'Janani Suraksha Yojana (JSY),' is unique in its scale, coverage and budget. In 2009-10 financial years, 15.4 billion was allocated to provide cash incentives to about 9.5 million women (36%) out of 26 million women estimated to give birth in India that year. 
JSY provides financial incentives to the pregnant women who receive three antenatal check-ups and opt for institutional deliveries. In states with poor maternal health indicators, the scheme included all pregnant women. However, in states like West Bengal, financial incentives are available to scheduled castes, scheduled tribes and below poverty line women aged 19 years or more up to two live births.  Under the scheme, 500/- is given to eligible pregnant women after 3 rd antenatal check-up in the 3 rd trimester 8-12 weeks before the expected date of delivery. Additional 200/- and 100/- are paid for institutional delivery to rural (total 700/-) and urban (total 600/-) pregnant women respectively for delivering in a government or accredited private Institution.
In the present context, this study is conducted to find out the institutional delivery rate, utilization rate of JSY among the eligible women and to identify the relation between cash benefit under JSY during antenatal period and institutional delivery .
A community-based, cross-sectional study was conducted in Bankura district of West Bengal among women who delivered in last 12 months during June-July 2008 using two stage revised 40-cluster sampling technique. The study obtained clearance from the Institutional Ethics Committee, B.S. Medical College, Bankura.
Bankura is a district in the western side of the state of West Bengal with 3.2 million population living in 22 community development blocks. Around 40% of the population belongs to scheduled castes and tribes.
The prevalence of institutional delivery in Bankura district, as reported in DLHS-2 (56.2%), was used for calculation of sample size.  Assuming 95% confidence level, 15% relative precision, design effect 2 and 10% non-response rate, the yielded sample size was 293. It was rounded off to 320 for an equal sub-sample of 8 from each of 40 clusters (villages and urban wards).
In the first stage, 40 clusters were selected from a list of all villages and urban wards of Bankura district using the probability proportional to size method. Each cluster was arbitrarily subdivided in four quadrants. In each quadrant, with a random start from the center, consecutive households were visited to select two willing women who delivered in last 12 months. All eligible women in the last household in each quadrant were included in the study.
After obtaining informed consent, trained interviewers collected information on age, caste, formal education, age at first marriage, age at first pregnancy, utilization status of different components of antenatal care, place of delivery, eligibility and utilization status of JSY through interviewing 324 study subjects and/or caretakers. Utilization of antenatal care and JSY was cross-checked from relevant documents, whenever available. Women received the cash benefit of five hundred rupees during antenatal period were considered as JSY availed women .
Analysis was done using SPSS (v.15.0) with duplicate entry to check consistency of the data. Binary logistic regression was done to identify the factors associated with institutional delivery.
Out of 324 women participated in the study, the proportion of scheduled castes and tribes was 41.4%. Only 5.3% women aged less than 19 years and more than two thirds (68.8%) belonged to the age group of 19-25 years. 46.0% women had no formal education and 13.3% had more than 10 years of formal education. 42.6% women had their first marriage before attaining 18 years and almost one third (30.6%) conceived before 19 years. Majority of women (65.1%) had their first pregnancy between 19 and 25 years.
Ultimately, 73.1% had institutional delivery out of which 11.1% were conducted in private facilities. Around one quarter of total deliveries (25.3%) were conducted by the unskilled birth attendants including traditional birth attendants.
More than half (52.8%) heard the phrase JSY and about one quarter of them (27.5%) knew all the benefits of JSY. Source of information was mostly (66.7%) auxiliary nurse midwives and Anganwari workers. Out of the study women, 198 (61.1%) were eligible for JSY. 3.7% were non-eligible due to age and parity whereas 35.2% were women above poverty line (APL). Among the eligible women, 100 (50.5%) received the benefits of JSY. The mean duration of education (7.5 ± 2.8 vs. 6.8 ± 2.8)), mean age at first marriage (18.5 ± 2.6 vs. 17.6 ± 1.9) and mean age at first pregnancy (20.0 ± 3.0 vs. 19.5 ± 2.4) were higher among non-eligible women compared to eligible women.
[Table 1] revealed that around half of the women who were not eligible for JSY (n=126) were registered early (≤12 weeks of gestation). The proportion was 40.0% among women who were eligible and availed JSY but far less in eligible and not availing subjects (28.9%). At least three antenatal check-ups (ANC) by the skilled birth attendants were received by almost 90% women of all three groups. Similarly around 97% women who delivered in last one year received adequate tetanus prophylaxis irrespective of their eligibility status for and utilization of JSY. The proportion of women who consumed at least 100 IFA tablets was lowest in non-eligible group and highest in women who were eligible and utilized the benefits of JSY. The proportion of institutional delivery was more among the study subjects who availed JSY (84.0%) than those who were not eligible (78.6%) or eligible but not availed the benefits of JSY (55.1). Around 23% women of non-eligible group preferred private facilities for child birth. The corresponding figures were 1 and 6% among JSY eligible women who were user and non-user respectively.
|Table 1: Distribution of maternal health services according to eligibility and utilization status of JSY|
Click here to view
After adjusting for age, education, age at first marriage, age at first pregnancy and different components of antenatal care, it was found that women who were eligible but not received JSY availed institutional delivery almost two times less whereas women who received JSY utilized institutional delivery two times more compared to non-eligible women. Women who consumed at least 100 IFA tablets in antenatal period availed two times more likely to had institutional delivery.
Overall almost three-fourth women availed the services of institutional delivery in Bankura district which is around 10% more than that reported in District Level Health and Facility Survey (DLHS-3).  Increase in the rate of institutional deliveries was also reported in five states of India in concurrent assessment of JSY.  Increasing trends of institutional deliveries were also reported in south Orissa.  Similar effect of cash incentive and voucher scheme was noted in Bangladesh. 
Low acquaintance with the term JSY and lack of adequate knowledge about the benefits of JSY compared to other states of India might be due to absence of deliberate probing and early stage of implementation .  Just over half of the eligible women received the cash benefits. Non-availability of Accredited Social Health Activists (ASHA) during study period in many areas of the district might play a role in awareness and utilization of JSY. It was noted that more than 40% of JSY eligible women did not receive the cash benefit during antenatal period in spite of fulfilling the preconditions. Lack of awareness, inability of beneficiaries to produce relevant documents (BPL/SC/ST certificates or any other documents favoring their caste or economic status), managerial / administrative weakness in early stage of implementation came out as possible reasons for this. Among those who availed JSY, nine did not receive three antenatal check-ups. Informal enquiries as to the reasons behind this revealed that some of the health workers could not follow the preconditions as strictly as specified in guidelines. This finding was corroborated by Lim et al., where they did not find explicit linkage between antenatal care and financial assistance from JSY despite preconditions of three antenatal check-ups. 
The coverage of three or more ANC and tetanus prophylaxis was around 90% or more among the study women irrespective of the status of eligibility and utilization of JSY. DLHS-3 also depicted the high coverage of those two indicators.  Coverage of early registration was highest in JSY non-eligible women followed by the women who received the cash benefits of JSY. Consumption of 100 or more IFA tablets was highest among women availing JSY. Earlier studies in India showed higher utilization of all components of antenatal care among women receiving cash benefits under JSY. ,, Demand side financing and cash incentives increased the demand of antenatal care services in rural Bangladesh.  Cash incentive increased the utilization of antenatal care including tetanus prophylaxis and iron supplementation in Honduras and Mexico. ,
The institutional delivery rate was highest among women who availed JSY. After adjustment for socio-demographic and health service related variables, availing JSY was found to be significantly associated with institutional deliveries [Table 2]. It corroborated with the findings of Lim et al., in a nation-wide study in India.  Underutilization of it by other section of JSY eligible women who did not avail it emphasized the role of cash incentives in promoting institutional deliveries. Interestingly, JSY non-eligible women with better socio-economic and cultural characteristics had a lower utilization of institutional deliveries. Despite their keenness toward maternal care services as shown by higher coverage of antenatal care, lower rate of institutional deliveries might be due to financial barriers in accessing obstetric care in need. So, expanding the cashless voucher scheme for referral transport to include all women may help many more women in accessing institutional care for child birth.
|Table 2: Multivariate analysis to identify factors favoring institutional delivery|
Click here to view
Preference of almost one quarter of JSY non-eligible women toward private facilities for their child birth may be taken as an opportunity to revisit the quality and accessibility issues of government health facilities.
Even with the present state of low penetration of JSY, the district traversed a considerable way forward in achieving the national target of institutional delivery rate.  So, with time and higher utilization of JSY, the rate of institutional delivery might be increased further.
In this small-scale study, it was evident that JSY was positively associated with the utilization and coverage of antenatal care and institutional deliveries in the district of Bankura, West Bengal.
| Acknowledgement|| |
The authors gratefully acknowledge the financial assistance from District Health and Family Welfare Samity, Bankura for conduction of the study.
| References|| |
|1.||Doetinchem O, Xu K, Carrin G. Conditional cash transfers: What's in it for health. World Health Organization. Geneva, Switzerland; 2008. |
|2.||Morris SS, Flores R, Olinto P, Medina JM. Monetary incentives in primary health care and effect on use and coverage of preventive health care interventions in rural Honduras: Cluster randomized trial. Lancet 2004;364:2030-7. |
|3.||Lagarde M, Haines A, Palmer N. Conditional cash transfer for improving uptake of health intervention in low and middle income countries: A systemic review. JAMA 2007;298:1900-10. |
|4.||Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation. Lancet 2010;375:2009-23. |
|5.||Government of India. Ministry of Health and family Welfare. Janani Suraksha Yojana: Features and frequently asked questions and answers. Available from: http://mohfw.nic.in/dofw%20website/JSY_features_FAQ_Nov_2006.htm. [Last Accessed on 2010 Mar 18]. |
|6.||Government of India. Ministry of Health and Family Welfare. District Level Household Survey under Reproductive and Child Health Project (DLHS-2): West Bengal: Bankura. International Institute of Population Sciences, Mumbai, India; 2004. |
|7.||Government of India. Ministry of Health and Family Welfare. District Level Household and Facility Survey under Reproductive and Child Health Project (DLHS-3): West Bengal: Bankura. International Institute of Population Sciences, Mumbai, India; 2009. |
|8.||UN Population Fund-India. Concurrent assessment of Janani Suraksha Yojana (JSY) in selected states: Bihar, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh. New Delhi: UN Population Fund-India; 2009. |
|9.||Malini S, Tripathi RM, Khattar P, Nair KS, Thekre YL, Dhar N, et al. A rapid appraisal of functioning of Janani Suraksha Yojana in South Orissa. Health Popul Perspect Issues 2008;31:126-31. |
|10.||Ahmed S, Khan MM. A maternal health voucher scheme: What have we learned from the demand-side financing scheme in Bangladesh? Health Policy Plan 2011;26:25-32. |
|11.||Barber SL, Gertler PJ. Empowering women to obtain high quality care: Evidence from an evaluation of Mexico's conditional cash transfer programme. Health Policy Plan 2009;24:18-25. |
|12.||Government of India. National Population Policy, Ministry of Health and Family Welfare. New Delhi; 2000. p. 1-39. |
[Table 1], [Table 2]