Conditional cash transfers and quality of maternal and newborn care: Women’s experience of the Janani Suraksha Yojana in

Rajasthan

KG Santhya, Shireen J Jejeebhoy, Rajib Acharya, AJ Francis Zavier

Population Council, New Delhi

Supported by the John D. and Catherine T. MacArthur Foundation

National Conference on Bringing Evidence into Public Health Policy

Bangalore, December 10-11, 2010

JSY: what we know and what we don’t

• Official statistics show a phenomenal increase in the number of JSY beneficiaries – 0.7 million in 2005-06 to 10.2 million in 2009-10; as of 06/10, a total of 32 million beneficiaries

• Recent evaluations suggest that JSY has indeed succeeded in increasing institutional deliveries and use of antenatal services

• Several evaluations of JSY exist, but limited information on the reach of the scheme to the most vulnerable and the extent to which the quality of maternal and newborn care services has improved or compromised with the introduction of JSY

Objective

Drawing on data obtained from a representative survey of some 5,000 women in Rajasthan, the objective is to present evidence on:

• The reach of JSY among the most vulnerable

• The effects of JSY on the quality of maternal and newborn care services

Study location

• Alwar and Jodhpur districts (purposively selected, representing the state averages in socio-demographic indicators)

• Relatively high fertility• Low literacy

• Both rural and urban areas• 3 blocks each in rural areas and 2-3 blocks in urban areas1

• Alwar: 48 PSUs from 76 villages & 50 PSUs from 135 CEBs2

• Jodhpur: 48 PSUs from 61 villages & 50 PSUs from 187 CEBs2

1Selection of blocks based on female literacy and % of SC/ST population2Selection of villages/urban wards proportional to size

Study tools, participants and response rates

• House-listing to identify eligible women, i.e., women aged <35 years who had delivered in the one year preceding the interview

• All eligible women identified invited to participate; women successfully interviewed – 4,770; response rate 80%

• Interviews with family members of women who had died (4)

• In-depth interviews with selected survey respondents/family members (52)

• Interviews with providers: ASHAs (150), ANMs (96), Medical officers (38)

• Survey of facilities: sub-centres (52), PHC (43)

Selected background characteristics of surveyed women

Characteristics Combined Urban Rural

Mean age 23.6 24.6 23.3

Median years of schooling completed 2.0 7.0 NC

% Hindu 77.8 72.9 79.3

% Muslim 20.6 24.8 19.4

% belonging to SC/ST 33.0 21.4 36.5

Mean SLI 22.8 31.1 20.2

Mean age at marriage 16.2 18.3 15.5

Mean number of pregnancies 3.0 2.5 3.1

Mean number of children ever born 2.6 2.1 2.7

Reach of JSY: How many are reached and is it reaching the most vulnerable?

How many are reached?

• Although all women in the state were eligible, fewer than half had received the cash

• Slightly more urban than rural women had received the cash

• Among those who had delivered at eligible govt./pvt. facilities, 92% had received the cash

• Among eligible women who had delivered at home, just 1 woman had received the cash

• A negligible minority of non-eligible women also had received the cash

% who had received cash

1 Of women who had delivered in model sub-centres, PHCs, CHCs, DH & accredited private hospitals2 Of those aged 19 and above, belonging to BPL households and having first or second deliveries3 Of the non-eligible deliveries, including those who delivered at home aged below 19, not belonging to BPL households and having 3+ parity, at sub-centres, non-accredited pvt hospitals and in transit

• Women who had delivered at young ages (<18) and at ages 30-34 less likely than others to have received the cash

• Women belonging to Muslim and other religions less likely than Hindu women to have received the cash

• Women belonging to poorer households less likely than others to have received the cash

• So were women with no schooling (not shown graphically)

Is it reaching the most vulnerable?

Effects of JSY: Has it contributed to improve the quality of maternal and newborn

care?

Effects of JSY: Analysis approach

• Comparison of experiences during pre-JSY birth (birth before Nov 2006) and the most recent birth (2009-10) of a matched sample of women who had experienced both pre- and post-JSY births1

• Matched sample arrived at using propensity score matching (N=1,246)

• Women categorized into JSY beneficiaries and non-beneficiaries, based on whether they had received JSY cash for the most recent birth

• Net effect of JSY assessed using difference-in-difference (DiD) estimation; regression models estimated, using difference in the outcome measures between pre-and post-JSY period as the dependent variable, to assess the net effect after controlling for potentially confounding factors1

1 after controlling for maternal age, education, household economic status. religion, caste, parity, place of residence, contact with ASHA

Measuring the effects of JSY: Indicators of quality of antenatal service

• Index of information on pregnancy-related care received (0-10)

women had received information on danger signs during pregnancy, importance of delivery preparations, expected date of delivery, danger signs during delivery, importance of institutional delivery, importance of postpartum check-ups, danger signs during the postpartum period, immediate breastfeeding, danger signs in the newborn and newborn care

• Index of comprehensive care received (0-7)

women had received the following components of care: weight measured, height measured, blood pressure checked, blood tested, urine tested, abdomen examined, and had an internal examination

• Measure of client-provider interaction (dichotomous)

HCP ever asked R whether she had any question/ concern to discuss with him/her, HCP had typically spent at least 10 minutes in consultation, and HCP had always treated R with respect

• Quality of antenatal services , in general, remains poor

• JSY effects on quality of antenatal services mixed

• Increase in the number of items about which information was received between pre- and post- JSY period slightly larger among beneficiaries than non-beneficiaries

• Improvements in comprehensive care received between pre-and post-JSY period slightly greater among beneficiaries than non-beneficiaries

• No change in the quality of client-provider interaction

Quality of antenatal services

Index of comprehensive care received

Index of information on pregnancy-related care received

%

Measure of client-provider interaction

Measuring the effects of JSY: Indicators of quality of delivery service

• Received basic check-ups prior to delivery (dichotomous)

HCP conducted abdominal & vaginal examination, and checked temperature and pulse

• Measure of provider availability and behaviour (dichotomous)

HCP was available when R reached the facility and HCP behaved nicely with R

• Discharged after 24 hours (dichotomous)

• Allowed the escort to remain with R during delivery (dichotomous)

• No change in the extent to which women received basic check-ups prior to delivery

• No change in the availability of provider and his/her behaviour towards the client

Received basic check-ups prior to delivery

Quality of delivery services

Measure of provider availability and behaviour

%

• Improvements in the practice of keeping women at the facility for >24 hours between pre- and post- JSY period considerable among beneficiaries (14 point increase) than among non-beneficiaries (6 point decline)

• Improvements in the practice of allowing the escort to remain with the woman during delivery between pre- and post- JSY period notable among beneficiaries (11 point increase) than among non-beneficiaries (5 point decline)

Quality of delivery services

Discharged after 24 hours Allowed the escort to remain with the woman

%

***

***

Measuring the effects of JSY: Indicators of quality of postpartum services

• Comprehensive check-ups received (dichotomous)

women’s blood pressure, temperature and vaginal bleeding had been checked

• Index of comprehensive information received (0-5)

women had received information on taking care of self, taking care of the baby, breastfeeding, immunization and postpartum contraception

• No change between pre- and post- JSY period in the extent to which women received comprehensive check-ups during the postpartum period

• Similar levels of improvements in the extent to which women received comprehensive information during postpartum check-ups among beneficiaries and non-beneficiaries

Quality of postpartum services

Comprehensive information receivedComprehensive check-up received

%

Measuring the effects of JSY: Indicators of quality of newborn care practices

• Comprehensive immediate care of the newborn (dichotomous)

the newborn was received by the person who attended the delivery rather than delivered on to the floor, the cord was cut immediately, no substance was applied on the cord stump, and the newborn was immediately wiped dry and wrapped and was not bathed immediately

• Followed appropriate feeding practices (dichotomous)

the newborn was not given pre-lacteal feeds, was breastfed immediately, and was fed colostrum

• Received full immunization for infants aged more than 4 months (dichotomous)

the infant had received BCG, three doses of oral polio and three doses of DPT vaccines

• Quality of newborn care received far from satisfactory

• Improvements in the practice of comprehensive immediate care of newborns between pre- and post-JSY births larger among beneficiaries than non-beneficiaries (18 points vs. 3 points)

• Improvements in the adoption of appropriate feeding practices, again, larger among beneficiaries than non-beneficiaries (10 points vs. 4 points)

• Improvements in full immunization, again, larger among beneficiaries than non-beneficiaries (16 points vs. 10 points)

Quality of newborn care services

Comprehensive immediate care of the newborn

%

Followed appropriate feeding practices

Immunization

Net effect of JSY: Results of difference-in-difference estimation

Indicators Effect

Index of information on pregnancy-related care received ++**

Index of comprehensive antenatal services received ++*

Measure of client-provider interaction No

Received basic check-ups prior to delivery No

Measure of provider availability and behaviour No

Discharged after 24 hours ++*

Allowed the escort to remain with R during delivery ++*

Comprehensive check-ups during the postpartum period No

Index of comprehensive information received No

Comprehensive immediate care of the newborn ++***

Followed appropriate feeding practices ++**

Full immunization No

Effects of JSY: women’s perceptions

• Women perceived improvements in several areas:• better provision of information on maternal and child health care

• safer management of delivery

• better treatment at the facility by the providers

• Improved access to services

• Coverage of some of the cost incurred for delivery

Earlier, there were no facilities, now there are so many facilities; earlier, no one used to go to hospitals, but now everyone goes to the hospital; earlier, no one used to get money, but now everyone gets money; earlier, we do not get so much advice or information, but now they advise about everything

• A small minority, however, perceived no improvement

There is no improvement because no one pays attention to the women. What would I do with that money if I had to face a problem and spend more money. There is no guarantee that the child would be delivered properly and would come home alive

Conclusions

• Reach of JSY remains inequitable – the most vulnerable are less likely than others to have received the benefit

• Evidence on quality of services presents mixed picture

• Positive with respect to indicators of antenatal services

• Mix of no change and positive change with respect to indicators of delivery services

• No change with respect to indicators of postpartum services

• Largely positive with respect to indicators of newborn care services

• Attention to ensuring the reach of the scheme to the most vulnerable and improving the quality of services important