Impact of Janani Suraksha Yojana on Institutional Delivery Rate and Maternal Morbidity and Mortality: An Observational Study in India

Article excerpt

ABSTRACT

The Government of India initiated a cash incentive scheme-Janani Suraksha Yojana (JSY)-to promote institutional deliveries with an aim to reduce maternal mortality ratio (MMR). An observational study was conducted in a tertiary-care hospital of Madhya Pradesh, India, before and after implementation of JSY, with a sample of women presenting for institutional delivery. The objectives of this study were to: (i) determine the total number of institutional deliveries before and after implementation of JSY, (ii) determine the MMR, and (iii) compare factors associated with maternal mortality and morbidity. The data were analyzed for two years before implementation of JSY (2003-2005) and compared with two years following implementation of JSY (2005-2007). Overall, institutional deliveries increased by 42.6% after implementation, including those among rural, illiterate and primary-literate persons of lower socioeconomic strata. The main causes of maternal mortality were eclampsia, pre-eclampsia and severe anaemia both before and after implementation of JSY. Anaemia was the most common morbidity factor observed in this study. Among those who had institutional deliveries, there were significant increases in cases of eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria after implementation of JSY. The scheme appeared to increase institutional delivery by at-risk mothers, which has the potential to reduce maternal morbidity and mortality, improve child survival, and ensure equity in maternal healthcare in India. The lessons from this study and other available sources should be utilized to improve the performance and implementation of JSY scheme in India.

Keywords: Conditional cash transfer; Institutional deliveries; Maternal mortality; Maternal survival; India

INTRODUCTION

The maternal morbidity and mortality have been recorded since antiquity and probably recognizing this fact, the universal declaration for human rights of 1948 in article 25 stressed that "Motherhood and childhood are entitled to special care and assistance" (1). Providentially, the maternal health issues continue to be at the forefront of global and national health policies in the last few years. The Millennium Development Goal 5 (MDG 5) calls for a three-fourth reduction in the maternal mortality ratio (MMR) by 2015 compared to 1990 levels (2-4). However, In spite all efforts, the progress in reducing maternal mortality is slow and, globally, an estimated 358,000 mothers died of pregnancy or related complications in 2008 (5). Approximately 99% (355,000) of these deaths occur in developing countries, 87% (313,000) in Africa and Asia, and more than half in 6 countries (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo) only (5-6). Additionally, over 50 million pregnant women each year suffer from morbidity due to acute complications from pregnancy globally (7). The MMR in India during 2004- 2006 was 254 per 100,000 livebirths with wide geographical variations, which slightly declined to 212 per 100,000 livebirths in 2007-2009 (8-10). Eight socioeconomically-backward states: Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal, and Uttar Pradesh, accounted for majority of maternal deaths in India (9).

Each death or long-term complication represents an individual tragedy for the woman, her partner, her children, and her family, although a large proportion of these maternal deaths is avoidable. The main causes are known, and more than 80% of maternal deaths could be prevented or avoided through either increasing the institutional deliveries or by improving the quality of care provided to the women (3-7). Unfortunately, as late as in 2005- 2006, the institutional deliveries in rural India were reported to be 28.9% (10-11). The Government of India gave high priority to promote institutional deliveries to improve maternal survival as part of national policy and also being a signatory for MDGs (4). …