Maternal health is the building block of any developing country. Ensuring the well being of mothers is to ensure the progress of society in terms of health and development of its citizens. Universal access to quality maternal care and neonatal care services is pivotal to achieving the first Sustainable Development Goal (SDG) – to reduce the global maternal mortality ratio to less than 70 per 1,00,000 live births by 2030. Efforts to reach this goal have to come from multiple fronts, but only the quality of services provided can ensure their sustainability.
India has a history of tackling maternal mortality with more than two decades of committed safe motherhood programming. In 1950 – 1970, maternal health care started on the right note as the first five-year plan focussed on target based family planning approach. But a considerable setback were forced sterilisations during the Emergency (1975 – 1977), leading to substandard childbirth care and overall maternal safety. The discussion around quality in maternal care in India came into play only in the 2000s, which was heavily influenced by national policies and economic development as well as global trends in health and development priorities. Quality of care encompasses both the technical competence of service providers and patient satisfaction with the treatment received.
Several studies have shown that states with the highest number of institutional deliveries accounted for far less Maternal Mortality Ratio (MMR) in the country. Kerala, for example, had the highest percentage of institutional deliveries, i.e. 97% and accounts for the lowest MMR in India; 110 maternal deaths per 100,000 live births. On the flip side, a state like Uttar Pradesh had 517 MMR with only 10% of institutional deliveries in 2001-2003. In light of this, the Government of India rolled out one of the most extensive conditional cash transfer programs in the world, Janani Suraksha Yojana 2005, (JSY). Conditional Cash Transfers (CCT) are quite popular in low or middle-income countries (World Bank, 2015). While JSY was designed to benefit new mothers and to increase institutional deliveries in states, it’s prime objective remains to lower the Maternal Mortality Rate.
Maternal Mortality Ratio (MMR) has seen a decline from 130 per 1 lakh live births in 2014-2016 to 122 per 1 lakh live births in 2015-2017. These achievements are a result of the quality of care provided in maternal institutional deliveries.
Janani Suraksha Yojana (JSY) was launched 12 April 2005, under the umbrella of National Rural Health Mission to modify the existing National Maternity Benefit Scheme. JSY integrated cash assistance with antenatal care during the pregnancy period, institutional care during delivery and the immediate postpartum period. The JSY program is a 100% centrally sponsored scheme. The proportion of institutional deliveries saw a phenomenal increase after the implementation of JSY, so much so up to 72% in 2009 and almost most of the beneficiaries belonged to disadvantaged sections of the society like Scheduled Castes women, Scheduled Tribes and other backward castes.
The JSY program is introduced and supported at the community level by accredited social health activists(ASHA), an incentivised village resident urging women to seek maternal health facilities in public health institutions over. This turned out to be a significant structural flaw in the JSY program. Incentives did motivate women to avail medical deliveries from local health institutions. Still, it did not improve other health indicators like postnatal check-ups or proportion of women consuming iron and folic tablets. Incentives matter, but it’s the incentive structure of the JSY program that has led to the collapse of other maternal health indicators in India. The role of ASHA workers is seen to deteriorate post-delivery especially in terms of postnatal visits as the efforts to locate the mother, the cost of travel etc, is higher than the small amount of cash received by them.
The central point of contestation is whether the implementation of JSY decreased the Maternal Mortality Rate in India. With the increase in institutional deliveries, the per-case fatality ratio did decrease with professional medical care. But this had little effect on MMR. The workload of healthcare workers and medical staff has also increased with institutional deliveries. The popularity of the JSY scheme has adversely affected the quality of treatment and emergency care given to pregnant women with complications.
The education and economic status of a woman are correlated. Moreover, these factors also influence the use of maternal care. Illiteracy and lack of information on maternal care lead women to neglect their physical well being from an early age. Empowering women through education about their physical, mental and sexual health should be an essential aim to elevate the maternal health sector. Educated women are better suited for going through the different complexities of pregnancies and seek healthcare support when needed. When it comes to bodily rights and maternal care in India, we see a clash of formal institutions such as the healthcare sector with the informal institutions of taboos, customs, code of conduct etc. The patriarchal Indian society doesn’t give women a say over their bodies, and they are not active agents when it comes to making decisions about their reproductive health. Issues like going to a hospital for childbirth, planned parenthood, postnatal care, safe abortions etc. still fall under the jurisdiction of the man or the elders of the family. This lack of autonomy prevents women from using available contraceptives, resulting in unintended or unwanted pregnancies. Child marriage is another cause for numerous young mothers, who are too young and too constrained to take care of themselves and their babies. Deaths due to post-delivery negligence or unsafe abortions are direct results of women being insufficiently informed and not seeking proper guidance from public health institutions. A policy as widespread as JSY should include monitoring informal institutions of marriage and parenting. JSY should provide for counselling on matters of family planning and abortions to affectively decrease MMR in India.
The opinions expressed in this essay are those of the authors. They do not purport to reflect the opinions or views of CCS.