title: State and socio-demographic group variation in out-of-pocket expenditure, borrowings and Janani Suraksha Yojana (JSY) programme use for birth deliveries in India.
abstract: BACKGROUND
  High out-of-pocket-expenditure (OOPE) deters families from seeking skilled/institutional care. 'Janani Suraksha Yojana (JSY), a conditional cash transfer programme launched in 2005 to mitigate OOPE and to promote institutional deliveries among the poor, is part of Government of India's efforts to achieve Millennium Development Goals (MDGs) 4 and 5. The objective of this study is to estimate variations in OOPE for normal/caesarean-section deliveries, JSY-programme use and delivery associated borrowings - by states and union territories, and socio-demographic profiling of families, in India.
  
  
  METHODS
  Secondary analysis of data from the District Level Household Survey (DLHS-3), 2007-08. Mean and median OOPE, percentage use of JSY and percentage of families needing to borrow money to pay for delivery associated expenditure was estimated for institutional and home deliveries.
  
  
  RESULTS
  Half (52%) of all deliveries in India occurred at home in 2007/08. OOPE for women having institutional deliveries remained high, with considerable variation between states and union territories. Mean OOPE (SD) of a normal delivery in public and private institution respectively in India were Rs. 1,624 and Rs. 4,458 and for a caesarean-section it was Rs. 5,935 and Rs. 14,276 respectively. There was considerable state-level variation in use of the JSY programme for normal deliveries (15% nationally; ranging from 0% in Goa to 43% in Madhya Pradesh) and the percentage of families having to borrow money to pay for a caesarean-section in a private institution (47% nationally; ranging from 7% in Goa to 69% in Bihar). Increased literacy and wealth were associated with a higher likelihood of an institutional delivery, higher OOPE but no major variations in use of the JSY.
  
  
  CONCLUSIONS
  Our study highlights the ongoing high OOPE and impoverishing impact of institutional care for deliveries in India. Supporting families in financial planning for maternity care, additional investment in the JSY programme and strengthening state level planning are required to increase the proportion of institutional deliveries.
authors.affiliation: South Asia Network for Chronic Disease (SANCD), Public Health Foundation of India (PHFI), C1/52, First Floor, Safdarjung Development Area, New Delhi 110 016, India. hanimi.reddy@phfi.org
authors.forename: Hanimi Reddy
authors.initials: HR
authors.lastname: Modugu
authors.forename: Manish
authors.initials: M
authors.lastname: Kumar
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D005382:Financing, Personal / Q000706:statistics & numerical data* / Q000639:trends; D005102:Health Expenditures; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000191:economics* / Q000706:statistics & numerical data*; D010350:Patient Credit and Collection / Q000191:economics*; D015397:Program Evaluation; D012959:Socioeconomic Factors