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Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R D Gardi Medical College, Ujjain, India.
2014 (English)In: PLoS ONE, ISSN 1932-6203, Vol. 9, no 5, e96773Article in journal (Refereed) Published
Abstract [en]


India launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30% in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter-facility referrals and study quality of referral services in JSY.

Methods and Results:

Women accessing intra natal care (n = 1182) at facilities (reporting >10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR-2.6, 95% CI: 1.0-6.6 p = 0.04). Maternal death record review (April 10-March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from <2 hours. Median time between arrival and death was 6.75 hours.


High odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.

Place, publisher, year, edition, pages
2014. Vol. 9, no 5, e96773
National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
URN: urn:nbn:se:umu:diva-91286DOI: 10.1371/journal.pone.0096773ISI: 000338213300071PubMedID: 24810416OAI: diva2:735444
Available from: 2014-07-28 Created: 2014-07-28 Last updated: 2015-12-17Bibliographically approved
In thesis
1. Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India
Open this publication in new window or tab >>Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: To accelerate the coverage of skilled birth attendance, in 2005, the Indian government initiated a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY) that provides cash to women upon delivering in health facilities. The attempt to increase the utilization of facilities through the JSY, given the health system’s fragile state, has raised concerns about the programme’s success at achieving its intended goal of reducing maternal mortality ratio (MMR).

Aim: To understand the implementation of the CCT policy to promote institutional births in India, with a special focus on nine of India’s poorer states.

Methods: Thesis uses both quantitative and qualitative methods. The changes in coverage and inequalities in institutional births in the nine states following the initiation of JSY were analysed by comparing levels before and during the programme using state and district level data. The association between the coverage of institutional births and MMR was assessed using regression analysis (I). The change in socioeconomic inequalities in institutional births was estimated using the concentration index and concentration curve, and contributions of different factors to inequalities was computed by decomposition analysis (II). The quality of referral services was studied by conducting a survey of health facilities (n=96) and post-partum women (n=1182) in three districts of Madhya Pradesh. Conditional logistic regression was used to study the association between maternal referrals and adverse birth outcomes, while spatial data for referrals were analysed using Geographical Information Systems (III). Semi-structured interviews were conducted with government and non-government stakeholders (n=11) to explore their perceptions of the JSY, and the data were analysed using a thematic framework approach (IV).

Results: In five years, institutional births increased significantly from a pre-programme average of 20% to 49%. However, no significant association between district-level institutional birth proportions and MMR was found (I). The inequality in access to institutional delivery care, although reduced since the introduction of JSY, still persists. Differences in male literacy, availability of emergency obstetric care (EmOC) in public facilities and poverty explained 69% of the observed inequality. While MMR has decreased in all areas since the introduction of JSY, it has declined four times faster in the richest areas than in the poorest (II). Adjusted odds for adverse birth outcomes among those referred were twice than in those who were not referred (AOR 2.6, 95% CI 1.1-6.6). A spatial analysis of the inter-facility transfer time indicated that maternal deaths occurred despite good geographic access to EmOC facilities (III). While most health officials considered stimulus in the form of JSY money to be essential to promote institutional births, non-government stakeholders criticised JSY as an easy way of addressing basic developmental issues and emphasised the need for improvements to health services, instead. Supply-side constraints and poor care quality were cited as key challenges to programme success, also several implementation challenges were cited (IV).

Conclusions: Although there was a sharp increase in coverage and a decline in institutional delivery care inequalities following the introduction of JSY, the availability of critical care is still poor. CCT programmes to increase service utilization need to be essentially supported by the provision of quality health care services, in order to achieve their intended impacts on health outcomes.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2015. 85 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1770
Maternal health, Condititonal cash transfer, Inequality, Referral, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-112844 (URN)978-91-7601-393-9 (ISBN)
Public defence
2016-01-15, Sal 135, Allmänmedicin, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Available from: 2015-12-18 Created: 2015-12-16 Last updated: 2015-12-17Bibliographically approved

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