|Year : 2016 | Volume
| Issue : 2 | Page : 118-123
A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India
Dipta K Mukhopadhyay1, Sujishnu Mukhopadhyay2, Sarmila Mallik3, Susmita Nayak4, Asit Kumar Biswas5, Akhil Bandhu Biswas6
1 Associate Professor, Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, West-Bengal, India
2 Associate Professor, Malda Medical College, Kolkata, India
3 Professor and Head, Department of Community Medicine, Murshidabad Medical College, Kolkata, West-Bengal, India
4 Consultant, Management, Institute of Health and Family Welfare, Kolkata, West-Bengal, India
5 Chief Medical Officer of Health, Darjeeling, Government of West Bengal, Kolkata, West-Bengal, India
6 Professor, Department of Community Medicine, Institute of Health and Family Welfare, Kolkata, West-Bengal, India
|Date of Web Publication||23-Jun-2016|
27/2A/1, Bakultala Lane, Kolkata - 700 042, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: India launched the Janani Suraksha Yojana (JSY) on the principles of conditional cash transfer providing monetary incentive to needy women to improve access to institutional childbirth. Objectives: This study was conducted among JSY-eligible women who delivered between April 2012 and June 2012 to assess the utilization of cash incentives toward institutional delivery, along with other associated factors influencing institutional delivery. Methods: It was a cross-sectional, descriptive study conducted between July 2012 and May 2013 on 946 women selected through stratified random sampling of subcentres from better and worse performing districts of West Bengal. Results: 74.7% of the study population was JSY-eligible. 90.2% of those who took three antenatal check-ups (ANCs) and 36.8% JSY-noneligible women received cash. Government institutions were preferred for childbirth among all groups irrespective of JSY eligibility, receipt of cash, and number of antenatal visits. Overall, 78.8% opted for institutional delivery if they had received cash, which was significantly more than those who did not (64.5%). JSY-eligible women were 1.5 times more likely to deliver in government institutions compared to JSY-noneligible women. With no incentive, the likelihood of institutional delivery was halved. The distance of a 24 Χ 7 delivery hub beyond 5 km (74.8% vs. 81.8%), the religion of Islam (62.7% vs. 83.2%), and multiparity (63.9% vs. 83.6%) were significant deterring factors. Conclusion: Despite some inclusion and exclusion errors, cash incentive under JSY was associated with increased institutional delivery, especially in government institutions though there were other factors influencing the decision as well.
Keywords: Conditional cash transfer (CCT), factors, institutional delivery, Janani Suraksha Yojana (JSY)
|How to cite this article:|
Mukhopadhyay DK, Mukhopadhyay S, Mallik S, Nayak S, Biswas AK, Biswas AB. A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India. Indian J Public Health 2016;60:118-23
|How to cite this URL:|
Mukhopadhyay DK, Mukhopadhyay S, Mallik S, Nayak S, Biswas AK, Biswas AB. A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India. Indian J Public Health [serial online] 2016 [cited 2019 Oct 16];60:118-23. Available from: http://www.ijph.in/text.asp?2016/60/2/118/184543
| Introduction|| |
The most influential factor responsible for the high burden of maternal mortality and morbidity in India is lack of access to quality obstetric care. ,, Absence of liquid cash at hand at the time of dire need could be the most deterring factor in opting for institutional obstetric care, which may be resolved by cash assistance.  Demand-side financing (DSF) was a worthwhile policy befitting the health needs of resource-constrained countries.  Conditional cash transfer (CCT), based on DSF approach, has been tried out to empower vulnerable populations to purchase health-care services. ,
The Government of India introduced the "Janani Suraksha Yojana (JSY)" (safe motherhood program) based on the principles of CCT. Under JSY, cash assistance was given to pregnant women receiving at least three antenatal check-ups (ANCs) and delivering at institutions. Women below poverty line (BPL) were also given cash incentive if they opted for home delivery. In states such as West Bengal, the scheme was for the marginalized women (Scheduled Castes, Scheduled Tribes, and those who belonged to BPL), aged at least 19 years and having less than two live births.  These restrictions were omitted later on. 
JSY has been claimed to have increased the rate of institutional deliveries.  However, the number of evidences remains meager. In a country such as India where demographic, socioeconomic, and health care provisions are all different across the country, it is imperative to assess the situation state-wise. In view of the above perspective, it was decided that a state-wide study would be conducted. The objectives of the study was first, to find out the utilization of cash incentives by the women delivering in the reference period of 1 year, and second to assess the factors associated with institutional deliveries in the state.
| Materials and Methods|| |
A cross-sectional, descriptive study was conducted between July 2012 and May 2013 among JSY-eligible women of West Bengal who had delivered between April 2012 and June 2012. Stratified random sampling method was applied to divide all the districts of the state in two strata based on the median institutional delivery rate. Three districts from the two strata were randomly selected. Thus, Purulia, Hooghly, and Cooch Behar represented as better performing districts while South 24 Parganas, Murshidabad, and Uttar Dinajpur represented the worse performing districts. Assuming the coverage of JSY scheme among the eligible women as 50%, confidence level of 95%, relative precision of 10%, design effect of 2, and nonresponse rate of 20%, the sample size was calculated to be 922. The lists of all subcenters, which totaled 3,795 in number, in the selected six districts were the sampling frame and 80 subcenters (clusters) were selected using probability proportional to size technique. Thus, 12 women were to be selected from each subcenter. A subcenter-wise list of JSY-eligible women was prepared with the help of the respective health workers. From that list, 12 women were selected randomly. In this way, the final sample size turned out to be 960.
Enumerators having exposure to public health programs were identified from the respective study districts and were trained in a daylong training program for the purpose of investigation. A subcenter-wise list of target women was prepared with the help of the frontline workers in all the selected subcenters. In each subcenter, 12 women were selected from that list through simple random sampling. After taking informed consent of the respondents, information on age, religion, caste, education, occupation, possession of BPL card, place of childbirth as well as eligibility and receipt of cash incentive under JSY were collected using a pretested, structured questionnaire through house-to-house visits. Data were collated and analyzed according to different sociodemographic factors; the hypotheses generated from there were tested with suitable statistical tests.
The present study had the clearance of the Institutional Ethics Committee of Bankura Sammilani (B.S.) Medical College, Bankura, West Bengal, India.
| Results|| |
Final analysis of the survey was done with data from 946 respondents residing in 80 subcenters, leaving aside 14 inconsistently filled-up questionnaires. About two-third (66.3%) of the respondents was aged 21-30 years, and nearly one-third were teenagers. The majority (69.7%) were Hindus. Nearly half of the study population represented the socially marginalized sections (36.4% Scheduled Castes, 5.9% Scheduled Tribes, and 3.6% Other Backward Classes). The majority (85.0%) were literates, with most of them having studied up to middle school (36.0%). Almost every 9 in 10 women (88.3%) were homemakers. About two-third (64.0%) families had BPL cards. The socioeconomic characteristics varied among the districts.
Out of the total study participants, considering all three criteria, nearly three-fourth (74.7%) were eligible for JSY. Almost all of them (96.3%) took three ANCs. In addition, more than one-third (36.8%) of JSY-ineligible women got the monetary assistance. Around 10% eligible women, even after fulfilling all preconditions, did not get the cash incentive. It was also revealed that government facilities were the preferred choice of the place of delivery, though in differing proportions in various groups among the women who received cash benefits under JSY irrespective of their eligibility [Figure 1].
|Figure 1: Preference of delivery among JSY-eligible women and noneligible women|
Note: The figures within the parentheses indicate percentages
Click here to view
Eligible women who received three ANCs had a higher rate of institutional delivery with preference for government health facilities than those who received less than three ANCs.
Around 90% of the JSY-eligible women received cash. Of them, deliveries at government, private, and home settings were chosen by 65.1%, 13.7%, and 21.2% of the women. The corresponding figures for those who did not receive it were 54.0%, 10.5%, and 35.5%, respectively. Thus, it was revealed from the figure that out of those eligible women, the rate of institutional delivery was significantly higher (78.8%) among those who received cash benefits than those (64.5%) who did not (χ = 7.8672, d.f. = 1, P = 0.005). But if we consider the choice of Government institutions only, then the difference between the women who received cash and who did not was marginally non-significant (χ = 3.6816, d.f. = 1, P = 0.0552).
Government facilities were chosen by 574 (60.7%) in the study population. We found that 81.2% of the women, if benefited, chose government facilities for their childbirth while only 18.8% did so even without having benefited. The rest of the women went to private facilities, or delivered en route0 or at home. This difference was statistically significant (χ = 21.479, P < 0.000). The significance is marginal (χ = 3.734, P = 0.053) if the distribution is between institutional and noninstitutional places of birth. However, subgroup analysis of the results showed that such relationships were not ubiquitous and interdistrict differences existed.
Digging further into collected data, we found that models of multivariate analysis fit well to reveal some additional information. For delivery in government Institutions, the model performed well as indicated by goodness of fit test from significant omnibus chi-square statistic (56.465, P < 0.001) and nonsignificant Hosmer-Lemeshow statistic (11.523, P = 0.63). The independent variables explained about 5.8-7.8% variation of the dependent variable as evident from Cox and Snell R square and Nagelkerke R square statistic. The model correctly classified 72.3% of the cases overall from the classification table. Binary logistic regression model also performed well in relation to delivery in any institution from significant omnibus statistic (112.788, P < 0.001) and nonsignificant Hosmer Lemeshow statistic (2.713, P = 0.951). Here, independent variables could explain 11.2-17% variation of the dependent variable as suggested from pseudo R-squared statistics. From the classification table, the model correctly classified 87.0% of the cases overall. It was found that compared to JSY-noneligible women, the possibility of choosing a public institution increased by one and a half times for those who were both JSY-eligible and duly assisted with cash. However, the JSY-eligible women who did not get cash benefit had a significantly lower chance of having an institutional delivery. Another significant factor was religion where we found that compared to the Hindus, other religions (predominantly Muslims) had almost half the probability of choosing an institution (public or private) for childbirth. It was also noted that compared to the primiparous women, the multiparous women were less inclined to choose a public facility and even lesser inclined to choose a private facility. As expected, the choice for public facilities was almost one and a half times more and that for all institutions was almost two times more in high-performing districts [Table 1].
|Table 1: Factors associated with delivery in any institution or in government institutions only|
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Factors such as lower age group of the mother, residence within 5 km of a functional delivery hub, awareness of the cash incentive, and home visit by a health worker were all related to childbirth at any government institution or any institution though the weight of the individual factors was different. Residing at a place that was more than 5 km from a functional delivery hub had a negative effect on opting for an institutional delivery and mathematically, the odds was found to be halved when compared to a residence that was in close proximity. Education beyond the primary level increased the odds for institutional deliveries only when private institutions were included. But such factors were all statistically insignificant. The most significant factor found in this study to have a relationship with government institutions was JSY-eligibility with cash incentive (AOR = 1.506).
| Discussion|| |
This state-wide descriptive study was conducted with the principal intent of gathering evidence toward the widely accepted view that JSY can have significant effects on the institutional delivery rate in a study setting and to statistically conclude on the strength of such a notion.  In systematic reviews on different DSF projects worldwide, it was noted that opinions were divided on the outcome of such efforts over the different parts of the world. Increased achievement in both antenatal visits and institutional deliveries were not reported from anywhere except India and Bangladesh. , The same studies have also indicated that improvement in ANCs was disproportionately less than the comparative increase in institutional deliveries, meaning that the effect of DSF at times can be equivocal. , Sometimes such initiatives have actually worsened the situation, as evidenced from an increased birth rate in Honduras and a higher cesarean section rate in Nepal. , So it may suffice to conclude that DSF can be a factor promoting institutional delivery but there are other confounders of importance that determine the overall effectiveness of such efforts, which Gopalan et al. wanted to amend for better effectiveness. 
Kesterton et al. have documented that the proportional improvement in recent years in institutional delivery has been mostly in the private for-profit sector than in the public sector.  However, there is a documented preoccupation in Eastern India, especially in West Bengal, in favor of the utilization of government facilities for inpatient care.  So, it is very natural that the consequential improvement in institutional deliveries would be more pronounced in the proportional childbirth there if the other conditions such as cost were met. It was observed in our study that the availability of cash, even to JSY-noneligible women did tilt the balance toward delivering in a government institution. Provision of cash may alter the behavior of other sections of the population, as noted in two studies in Rajasthan as well. ,
A study from Madhya Pradesh documented a 43% increase between before and after the implementation of JSY.  Although comparable statistical analysis is hard to come by, multivariate analysis in the current study identified cash incentive as the most important factor behind opting for an institution for delivery, more so if the institution was a government one. In addition, a JSY-eligible population, if not provided with the incentive would run the risk of halving their chances to decide in favor of an institutional delivery. The results of our study toes the same line as the systematic review by Murray et al., which had concluded that CCTs can help to improve the use of priority maternal services including birth in health care facilities. 
The decision against an institutional delivery by Muslims has been documented in other studies conducted in the state.  First pregnancy as a factor favoring institutional delivery was also found in Madhya Pradesh.  A very similar result was obtained in an earlier study in West Bengal where multipara women, having had an uneventful previous delivery, had decided against institutional delivery, especially if it was a private one.  The present study also reiterated that residing at a place far away from a 24 × 7 delivery center can be a deterrent to access formal care.  A relationship between maternal education and institutional delivery was found in Madhya Pradesh, with the proportion of illiterate women accessing formal care increasing significantly after implementation of JSY.  However, that sort of an association was not obtained in our study. The quality of ANC has been attributed as an important factor behind deciding for institutional care. In Ethiopia, Odo et al. calculated an AOR of 2.7 for this factor.  A similar observation was available from Odisha, India as well.  The issue of home visits by health workers, which may be taken as an proxy indicator of quality of ANC, was not found to be a significant factor behind the selection of birth place. It may mean that ANC was ineffective in making the women choose an institution for delivery.
Hence, based on the findings of the study we may conclude that provision of cash incentive is the most crucial step influencing access to formal institutional care for childbirth. However, in the same breath it has to be acknowledged that there are other factors and issues as well, both on the demand and supply sides, which may confound the impact of the scheme. In a way, all DSF schemes may improve the autonomy of women in the decision-making about their reproductive health.  As Murray et al. have commented, there is little evidence that it alone can be used to improve the quality of care in maternal health provision.  The coverage of JSY was neither equitable nor similar in all the different areas where this study was conducted. The effect of JSY on the ultimate of maternal and child health (MCH) care, i.e., reduction in maternal mortality was beyond the objectives of this study. But the less than justified odds that were found for the quality of antenatal care toward institutional delivery have prompted us to reiterate the remarks of Lim et al., namely, that there is no scope of complacency for the success we had with JSY; the authorities must improve the quality of maternal care even further to conquer the final frontiers of maternal care by increasing the access to and effectiveness of the program. 
Financial support and sponsorship
West Bengal State Family Welfare Samity, (a/c RCH).
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Trends in maternal mortality: 1990 to 2013: Estimates by WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division. Geneva, Switzerland: WHO; 2014. p. 26-7.
Odo DB, Shifti DM. Institutional delivery service utilization and associated factors among child bearing age women in Goba Woreda, Ethiopia. J Gynaecol Obstet 2014;2:63-70.
Varma DS, Khan ME, Hazra A. Increasing institutional delivery and access to emergency obstetric care services in rural Uttar Pradesh. J Fam Welfare 2010;56:23-30.
Jain AK. Janani suraksha yojana and the maternal mortality ratio. Econ Polit Wkly 2010;45:15-6.
Bellows NM, Bellows BW, Warren C. The use of vouchers for reproductive health services in developing countries: Systemic review. Trop Med Int Health 2011;16:84-96.
Doetinchem O, Xu K, Carrin G. Conditional Cash Transfers: What′s in it for Health? World Health Organization. Geneva, Switzerland: WHO; 2008. p. 1-3.
Standing H. Understanding the ′Demand Side′ in Service Delivery: Definitions, Frameworks and Tools from the Health Sector. London, UK: DFID Health System Resource Center; 2004. p. 3-40.
Government of India. Removal of conditionalities associated with parity and minimum age of mother for institutional deliveries in high performing states and for home deliveries in all States/UTs under Janani Suraksha Yojana (JSY). New Delhi, India: Ministry of Health and Family Welfare. Available from: www.wbhealth.gov.in/notice/hfw1002.pdf
. [Last accessed on 2010 Mar 18].
Gupta SK, Pal DK, Tiwari R, Garg R, Srivastava AK, Sarawagi R, et al.
Impact of janani suraksha yojana on institutional delivery rate and maternal moridity and mortality: An observational study in India. J Health Popul Nutr 2012;30:464-71.
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.
Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilization, experiences and outcomes of maternity care in low- and middle-income countries: A systematic review. BMC Pregnancy Childbirth 2014;14:30.
Gopalan SS, Durairaj V. Addressing maternal healthcare through demand side financial incentives: Experience of Janani Suraksha Yojana in India. BMC Health Serv Res 2012;12:319.
Morris SS, Flores R, Olinto P, Medina JM. Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: Cluster randomized trial. Lancet 2004;364:2030-7.
Powell-Jackson T, Hanson, K. Financial incentives for maternal health: Impact of a national programme in Nepal. J Health Econ 2012;31:271-84.
Gopalan SS, Mutasa R, Friedman J, Das A. Health sector demand-side financial incentives in low- and middle-income countries: A systematic review on demand- and supply-side effects. Soc Sci Med 2014;100:72-83.
Kesterton AJ, Kleland J, Slogett A, Ronsmans C. Institutional delivery in rural India: The relative importance of accessibility and economic status. BMC Pregnancy Childbirth 2010;10:30.
Sharma MP, Soni SC, Bhattacharya M, Datta U, Gupta S, Nandan D. An assessment of institutional deliveries under JSY at different levels of health care in Jaipur district, Rajasthan. Indian J Public Health 2009;53:177-82.
Iyengar SD, Iyengar K, Gupta V. Maternal health: A case study of Rajasthan. J Health Popul Nutr 2009;27:271-92.
Mukhopadhyay DK, Mukhopadhyay S, Bhattacharjee S, Nayak S, Biswas AK, Biswas AB. Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal. Indian J Public Health 2013;57:147-53.
Pariyo GW, Mayora C, Okui O, Ssengooba F, Peters DH, Serwadda D, et al
. Exploring new health markets: Experiences from informal providers of transport for maternal health services in Eastern Uganda. BMC Int Health Hum Rights 2011;11(Suppl 1):S10.
Annual Health Survey - Key Highlights for Odisha. Bhubaneswar. Available from:
. [Last accessed on 2013 Dec 8].