title: India's Conditional Cash Transfer Programme (the JSY) to Promote Institutional Birth: Is There an Association between Institutional Birth Proportion and Maternal Mortality?
abstract: India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR.
  
  
  
  Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above- mentioned nine states were analysed to assess relationship between MMR and institutional births.
  
  
  
  Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = -0.11).The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68].
  
  
  
  Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.
authors.affiliation: Department of Public Health, R. D. Gardi Medical College, Ujjain, India ; Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.
authors.forename: Bharat
authors.initials: B
authors.lastname: Randive
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D000328:Adult; D001723:Birth Rate; D016550:Birthing Centers / Q000191:economics* / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000191:economics*; D005260:Female; D005380:Financing, Government; D006297:Health Services Accessibility; D006801:Humans; D007194:India / Q000453:epidemiology; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality / Q000639:trends*; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D012052:Reimbursement, Incentive / Q000191:economics*