India’s economy is booming, with traffic-choked roadways and skyscrapers going up in Delhi and other cities. But across vast swathes of the countryside, poor women are still dying in childbirth, and infants are dying in their first weeks of life.
India has one of the highest maternal mortality rates in the world. A quarter of all maternal deaths globally occur in India. An estimated 254 Indian mothers die during pregnancy, childbirth, or the six weeks after delivery for every 100,000 births. The rate is as high as 480 maternal deaths in the most impoverished regions of the country. Infant mortality, too, is high. About 39 of every 1,000 Indian newborns die before they are one month old.
Distance, Cost, and Culture Are Barriers to Institutional Delivery
Why are so many mothers and babies still dying in a country that has made rapid economic progress? A key reason is that less than half of rural Indian births take place in a hospital or clinic, where skilled medical attention and life-saving equipment are available.
Most rural Indian women give birth at home, with the help of a family member or traditional midwife. When something goes wrong — such as obstructed labor — the result can be disastrous for the mother or baby. The leading cause of maternal deaths in India is hemorrhage, something that rarely happens in the case of hospital births.
Distance and cost dissuade many pregnant women, especially the poorest and least educated, from choosing a hospital birth. In remote rural areas, the nearest health facility may be many kilometers away. Roads are rough, and transport scarce and costly. Family members who accompany the woman to the hospital lose wages and will face expenses for their stay.
Cultural factors, too, come into play. Where the status of women is low, families may see childbirth as something that doesn’t merit a trip to the hospital. Women who belong to scheduled castes and tribes may fear they will encounter discrimination. And husbands sometimes refuse to allow their wives to be attended by male doctors.
India’s JSY Program Provides Cash Payments for Hospital Births
The Indian government hopes that a cash incentive can raise the proportion of women who choose to deliver in hospitals, which in turn will reduce infant mortality and maternal mortality.
Toward that end, the government in 2005 launched Janani Suraksha Yojana, or “Safe Motherhood Scheme.” The JSY program offers women small, one-time cash payments to deliver in a hospital or clinic, targeting households below the poverty line. The payments range up to about $30 — about three weeks’ income for a rural farm family.
The program uses female health workers called ASHAs, village women who are trained and employed to work with the families of expectant mothers. They visit the pregnant woman at home, counsel her to choose a hospital birth, and help her receive prenatal care. When the woman goes into labor, the ASHA accompanies her to the hospital and stays with her until she is discharged. Afterward, the ASHA encourages the mother to breastfeed and immunize her infant.
Early Research Shows JSY Program Lowering Infant Mortality Rates
A first major study of the JSY program, published in The Lancet on July 15, 2010, found encouraging results. The cash payments appear to have significantly increased the proportion of Indian women who receive prenatal care and give birth in hospitals.
The study found a clear impact on perinatal and neonatal mortality. JSY payments were associated with approximately 4 fewer deaths in the first week of life per 1,000 pregnancies, and 2 fewer deaths in the first four weeks of life per 1,000 births. Data on maternal mortality are still being analyzed.
Still, serious challenges remain. Implementation of the program is uneven across the country, with as few as 5 percent or as many as 44 percent of poor pregnant women participating in different states. The poorest and least educated women are not always the ones receiving the cash. Targeting needs to be improved to make sure the payments reach the neediest women.
A second problem is the uneven quality of obstetric care offered in health facilities. Even cash incentives won’t persuade women to deliver in hospitals if they expect to face discrimination or receive low-quality care. India needs to continue improving its health infrastructure and training skilled birth attendants and female health workers if the JSY program is to succeed.
Also see:
Maternal Mortality Declines Worldwide but Poorest Countries Lag
Female Health Workers Key to Reducing Maternal Mortality
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