Access alone is not enough?

In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery…Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

A new paper by Randive and colleagues in PLoS One suggests that the proportion of institutional births more than doubled in 5 years from 20% to 49% in nine states in India where women have been receiving cash incentives to deliver in health facilities since 2006. The authors do not find an association between facility deliveries and maternal mortality. They cite quality of care as a missing ingredient.

This seems reasonable. The need for improvements in quality of care in maternal health is covered extensively in this PLoS collection.

Overall, however, the pre-post analysis leaves us with some questions about the causal relationship between cash transfers and facility deliveries.

Our analysis of the nine states indicates a steep rise in institutional birth proportions since the inception of the JSY programme. Although available data do not allow segregation of institutional births into JSY and non-JSY births, a large part of this increase in institutional births is fuelled by the JSY.

This might be true, but I don’t see it in the data the authors present. Our friends at RHVouchers found something similar in Kenya with a voucher scheme and include a comparison group. Check them out for more info on demand-side strategies for maternal healthcare.