title: Effectiveness of demand and supply side interventions in promoting institutional deliveries--a quasi-experimental trial from rural north India.
abstract: BACKGROUND
  We assessed the differential and sequential effects of a Government of India conditional cash transfer scheme for the socio-economically disadvantaged (Janani Suraksha Yojana; JSY) and the strengthening of the primary health centre (PHC) network to provide 24/7 obstetric care in promoting institutional deliveries.
  
  
  METHODS
  This study used 7796 births from the Ballabgarh Health and Demographic Surveillance Site between April 2006 and March 2010 when both schemes were implemented in a staggered manner. The multiple baseline design took advantage of interventions separated by time and geographical zone to compute difference in differences in the rate of institutional deliveries. Logistic regression was used to estimate increases in the odds of institutional deliveries after adjustment for caste and maternal education.
  
  
  RESULTS
  Compared with villages with poor access, institutional deliveries nearly doubled among villages with access to 24/7 delivery services; odds ratio (OR) 1.9 [95% confidence interval (CI): 1.3, 2.6]. Introduction of JSY in villages with poor access resulted in a 1.4-fold (95% CI: 1.1, 1.8) increase in institutional deliveries and a 1.1-fold (95% CI: 0.9, 1.4) increase in villages served by PHCs 24/7. However, the introduction of PHC 24/7 care to villages served by JSY doubled the rate of institutional deliveries; OR 2.1 (95% CI: 1.5, 2.8). Among the disadvantaged, institutional deliveries increased by 34.4%, compared with 24.8% among the non-disadvantaged. Introduction of PHC 24/7 care in this group increased institutional deliveries 4-fold; OR 4.2 (95% CI: 1.9, 9.0) compared with 3-fold for JSY alone; OR 3.2 (95% CI: 1.8, 5.6).
  
  
  CONCLUSIONS
  Both demand and supply side strategies are effective and promote equity. Improving service delivery in a population previously primed by demand side intervention appears to be the most useful.
authors.affiliation: Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Senthil
authors.initials: S
authors.lastname: Amudhan
authors.forename: Kalaivani
authors.initials: K
authors.lastname: Mani
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Rai
authors.forename: Chandrakant S
authors.initials: CS
authors.lastname: Pandav
authors.forename: Anand
authors.initials: A
authors.lastname: Krishnan
mesh_terms: D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006268:Health Facilities / Q000191:economics / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D007194:India; D016015:Logistic Models; D008427:Maternal Health Services / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D012424:Rural Population
keywords: Institutional deliveries; Millennium Development Goals; access to health care; conditional cash transfer; incentive; multiple baseline design; primary health centre