A program in India that pays women to give birth in a health facility appears to be saving newborns’ lives and lowering the number of stillbirths, as demonstrated by research conducted by IHME. The study, India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation, is the first independent evaluation of the largest cash payment program in public health, a program expected to reach 10 million women in India.The study was conducted in collaboration with the Public Health Foundation of India.
Women who took part in the national government’s Janani Suraksha Yojana (JSY) program had 4 fewer stillbirths and deaths in the first week of life for every 1,000 pregnancies and 2 fewer neonatal deaths per 1,000 live births.
There were wide variations from state to state, both in the implementation and in the effects of the program. In the period 2007-2008, some states in India saw as few as 5% of all pregnant women participating in the program. In other states, as many as 44% of pregnant women participated. The largest increases in the proportion of women delivering in a health facility happened in the same states where more women participated in JSY.
Cash payments from JSY were also associated with a significantly higher proportion of women receiving prenatal care.
The poorest and least educated women appeared to be participating in JSY to a slightly lesser extent than women with moderate levels of education and income.
IHME and its collaborators gathered data from India’s nationwide district-level household surveys done in the periods from 2002 to 2004 and from 2007 to 2009 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics. They used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on prenatal care, in-facility births, and perinatal, neonatal, and maternal deaths.
Because JSY is the largest program of its kind in the world, it has implications for global health policy in other settings. About 1 out of every 5 child deaths occurs in India, and about 1 out of every 5 maternal deaths also occurs in India. This makes finding ways to reduce child and maternal deaths in India a critical part of achieving the Millennium Development Goals on improving maternal and child health. Part of IHME’s mission is to evaluate large-scale programs such as JSY to help policymakers decide where to spend limited global health resources.
Recommendations for future work
Because the program is aimed at the poorest and least educated women, more data should be collected on the demographic characteristics of JSY recipients, and more effort needs to be made to identify barriers that prevent women from taking advantage of the JSY program.
As the program continues, the researchers proposed that the government develop new ways to gather data on maternal deaths. The data were insufficient to determine whether JSY was lowering maternal deaths.
Additional assessments could be made of India’s health infrastructure, availability of qualified medical staff, and the quality of care that women are receiving in light of the strain that additional in-facility births may be putting on the health system.
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. The Lancet. 2010 Jun 4; 375:2009–2023.