Unintended effects of Janani Suraksha Yojana on maternal care in India

A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India

BACKGROUND

India's progress in reducing maternal and newborn mortality since the 1990s has been exemplary across diverse contexts. This paper examines progress in two state clusters: higher mortality states (HMS) with lower per capita income and lower mortality states (LMS) with higher per capita income.

METHODS

We characterised state clusters' progress in five characteristics of a mortality transition model (mortality levels, causes, health intervention coverage/equity, fertility and socioeconomic development) and examined health policy and systems changes. We conducted quantitative trend analyses, and qualitative document review, interviews and discussions with national and state experts.

RESULTS

Both clusters reduced maternal and neonatal mortality by over two-thirds and half respectively during 2000-2018. Neonatal deaths declined in HMS most on days 3-27, and in LMS on days 0-2. From 2005 to 2018, HMS improved coverage of antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) by over three-fold. In LMS, ANCq, institutional delivery and PNC rose by 1.4-fold. C-sections among the poorest increased from 1.5% to 7.1% in HMS and 5.6% to 19.4% in LMS.Fewer high-risk births (to mothers <18 or 36+ years, birth interval <2 years, birth order 3+) contributed 15% and 6% to neonatal mortality decline in HMS and LMS, respectively. Socioeconomic development improved in both clusters between 2005 and 2021; HMS saw more rapid increases than LMS in women's literacy (1.5-fold), household electricity (by 2-fold), improved sanitation (3.2-fold) and telephone access (6-fold).India's National (Rural) Health Mission's financial and administrative flexibility allowed states to tailor health system reforms. HMS expanded public health resources and financial schemes, while LMS further improved care at hospitals and among the poorest.

CONCLUSION

Two state clusters in India progressed in different mortality transitions, with efforts to maximise coverage at increasingly advanced levels of healthcare, alongside socioeconomic improvements. The transition model characterises progress and guides further advances in maternal and newborn survival.

A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India

BACKGROUND

There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY).

METHODS

We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics.

RESULTS

At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled.

CONCLUSION

Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.

Interventions in Maternal Anaemia to Reduce Maternal Mortality Rate Across India

Anaemia is one of the most prevalent issues encountered throughout pregnancy, with Iron deficiency anaemia and megaloblastic anaemia being the most common causes in India. It is critical to address anaemia in pregnancy since it has been linked to adverse pregnancy outcomes like preterm delivery, low-birth-weight newborns, fetal mortality, and, in certain circumstances, maternal death. The maternal mortality rate (MMR) is one of the significant health challenges, particularly in developing countries. It has substantially impacted the population's social situation and requires quick management. In this review article, we discuss recent developments and advancements in treating maternal anaemia with the aid of some government health programs, which can help with lowering the risk of maternal mortality. The primary goal of this manuscript is to raise awareness about anaemia in pregnancy. We examined the literature on anaemia during pregnancy, with a view to offering current and unambiguous guidance for preventing and managing this illness, which, if not appropriately managed, can result in severe maternal and neonatal problems.

Chronic diseases and productivity loss among middle-aged and elderly in India

CONTEXT

Chronic diseases are growing in India and largely affecting the middle-aged and elderly population; many of them are in working age. Though a large number of studies estimated the out-of-pocket payment and financial catastrophe due to this condition, there are no nationally representative studies on productivity loss due to health problems. This paper examined the pattern and prevalence of productivity loss, due to chronic diseases among middle-aged and elderly in India.

METHODS

We have used a total of 72,250 respondents from the first wave of Longitudinal Ageing Study in India (LASI), conducted in 2017-18. We have used two dependent variables, limiting paid work and ever stopped work due to ill health. We have estimated the age-sex adjusted prevalence of ever stopped working due to ill health and limiting paid work across MPCE quintile and socio- demographic characteristics. Propensity Score Matching (PSM) and logistic regression was used to examine the effect of chronic diseases on both these variables.

FINDINGS

We estimated that among middle aged adults in 45-64 years, 3,213 individuals accounting to 6.9% (95%CI:6.46-7.24) had ever-stopped work and 6,300 individuals accounting to 22.7% (95% CI: 21.49-23.95) had limiting paid work in India. The proportion of ever-stopped and limiting work due to health problem increased significantly with age and the number of chronic diseases. Limiting paid work is higher among females (25.1%), and in urban areas (24%) whereas ever-stopped is lower among female (5.7%) (95% CI:5.16-6.25 ) and in urban areas (4.9%) (95% CI: 4.20-5.69). The study also found that stroke (21.1%) and neurological or psychiatric problems (18%) were significantly associated with both ever stopped work and limiting paid work. PSM model shows that, those with chronic diseases are 4% and 11% more likely to stop and limit their work respectively. Regression model reveals that more than one chronic conditions had a consistent and significant positive impact on stopping work for over a year (increasing productivity loss) across all three models.

CONCLUSION

Individuals having any chronic disease has higher likelihood of ever stopped work and limiting paid work. Promoting awareness, screening and treatment at workplace is recommended to reduce adverse consequences of chronic disease in India.

Decadal change in the association between the status of young mother's Body Mass Index and anaemia with child low birth weight in India

Background

The study aims to investigate the changes in the socio-economic and demographic status of young mothers of age 15–24 years and to examine the association between mothers’ nutrition, i.e., Body Mass Index (BMI) and anaemia with child low birth weight for almost two decades during 1998–2016 in India.

Methods

National Family Health Survey (NFHS) round II and IV were used. The sample of this study included 3405 currently married young mothers from NFHS II and 44,742 from NFHS IV who gave birth at least one child in the last three years preceding the surveys. Logistic regression and Blinder-Oaxaca decomposition analysis have been used in this study to examine the corresponding association between the concerned variables.

Results

The analysis showed that the prevalence of low birth weight (LBW) babies has decreased from 26.1 to 22.8 for the 15 to 19 age group and from 20.4 to 18.7 for the 20 to 24 age group over time. Young mothers with low BMI or severe anaemia have shown higher odds of having LBW babies. For instance, the odds of having a LBW child was 1.44 (p-value = 0.000; 95% CI: 1.05, 1.65) for mothers with low BMI and 1.55 (p-value = 0.000; 95% CI: 1.27, 1.90) with severe anaemia. Over the decade, the association of LBW babies with mothers’ nutrition has decreased. The odds of LBW with mothers with low BMI decreased from 1.63 (p-value = 0.004; 95% CI: 1.21, 2.21) to 1.41 (p-value = 0.000; 95% CI: 1.27, 1.55). Similarly, mothers with severe anaemia, the odds of LBW child decreased from 2.6 (p-value = 0.000; 95% CI: 1.75, 3.8) in 1998 to 1.3 (p-value = 0.024; 95% CI: 1.02, 1.65) in 2016.

Conclusions

The maternal and child health improvement in India has been moderate over the decade. Still, a significant proportion of the women are suffering from poor health and young mothers are at more risk to deliver LBW babies. It is highly recommended to integrate maternal and child health programmes with the ongoing health policies to improve the situation while taking additional care of the young pregnant mother and their nutritional health.

S. Level of inequality and the role of governance indicators in the coverage of reproductive maternal and child healthcare services: Findings from India

BACKGROUND

Diligent monitoring of inequalities in the coverage of essential reproductive, maternal, new-born and child health related (RMNCH) services becomes imperative to smoothen the journey towards Sustainable Development Goals (SDGs). In this study, we aim to measure the magnitude of inequalities in the coverage of RMNCH services. We also made an attempt to divulge the relationship between the various themes of governance and RMNCH indices.

METHODS

We used National Family Health Survey dataset (2015-16) and Public Affairs Index (PAI), 2016 for the analysis. Two summative indices, namely Composite Coverage Index (CCI) and Co-Coverage (Co-Cov) indicator were constructed to measure the RMNCH coverage. Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were employed to measure inequality in the distribution of coverage of RMNCH. In addition, we have used Spearman's rank correlation matrix to glean the association between governance indicator and coverage indices.

RESULTS & CONCLUSIONS

Our study indicates an erratic distribution in the coverage of CCI and Co-Cov across wealth quintiles and state groups. We found that the distribution of RII values for Punjab, Tamil Nadu, and West Bengal hovered around 1. Whereas, RII values for Haryana was 2.01 indicating maximum inequality across wealth quintiles. Furthermore, the essential interventions like adequate antenatal care services (ANC4) and skilled birth attendants (SBA) were the most inequitable interventions, while tetanus toxoid and Bacilli Calmette- Guerin (BCG) were least inequitable. The Spearman's rank correlation matrix demonstrated a strong and positive correlation between governance indicators and coverage indices.

Pro-poor policies and improvements in maternal health outcomes in India

BACKGROUND

Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997-2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India.

METHODS

This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015-16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India.

RESULTS

On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors.

CONCLUSIONS

The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India's impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.

Institutional deliveries in India's nine low performing states: levels, determinants and accessibility

Background

Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality.

Objective

This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities.

Methods

A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings.

Results

Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility.

Conclusions

The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.

Understanding equity of institutional delivery in public health centre by level of care in India: an assessment using benefit incidence analysis

BACKGROUND

The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India.

METHODS

Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015-16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis.

RESULTS

Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015-16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was - 0.161 [95% CI, - 0.158, - 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres.

CONCLUSION

Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India.