title: An assessment of the impact of the JSY cash transfer program on maternal mortality reduction in Madhya Pradesh, India.
abstract: BACKGROUND
  The Indian Janani Suraksha Yojana (JSY) program is a demand-side program in which the state pays women a cash incentive to deliver in an institution, with the aim of reducing maternal mortality. The JSY has had 54 million beneficiaries since inception 7 years ago. Although a number of studies have demonstrated the effect of JSY on coverage, few have examined the direct impact of the program on maternal mortality.
  
  
  OBJECTIVE
  To study the impact of JSY on maternal mortality in Madhya Pradesh (MP), one of India's largest provinces.
  
  
  METHODS
  By synthesizing data from various sources, district-level maternal mortality ratios (MMR) from 2005 to 2010 were estimated using a Bayesian spatio-temporal model. Based on these, a mixed effects multilevel regression model was applied to assess the impact of JSY. Specifically, the association between JSY intensity, as reflected by 1) proportion of JSY-supported institutional deliveries, 2) total annual JSY expenditure, and 3) MMR, was examined.
  
  
  RESULTS
  The proportion of all institutional deliveries increased from 23.9% in 2005 to 55.9% in 2010 province-wide. The proportion of JSY-supported institutional deliveries rose from 14% (2005) to 80% (2010). MMR declines in the districts varied from 2 to 35% over this period. Despite the marked increase in JSY-supported delivery, our multilevel models did not detect a significant association between JSY-supported delivery proportions and changes in MMR in the districts. The results from the analysis examining the association between MMR and JSY expenditure are similar.
  
  
  CONCLUSIONS
  Our analysis was unable to detect an association between maternal mortality reduction and the JSY in MP. The high proportion of institutional delivery under the program does not seem to have converted to lower mortality outcomes. The lack of significant impact could be related to supply-side constraints. Demand-side programs like JSY will have a limited effect if the supply side is unable to deliver care of adequate quality.
authors.affiliation: Division of Global Health, Department of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden; Institution of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
authors.forename: Marie
authors.initials: M
authors.lastname: Ng
authors.affiliation: Department of Health and Family Welfare, National Rural Health Mission, Government of Madhya Pradesh, Bhopal, India.
authors.forename: Archana
authors.initials: A
authors.lastname: Misra
authors.affiliation: Division of Global Health, Department of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden; RD Gardi Medical College, Ujjain, India.
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.affiliation: Department of Health and Family Welfare, National Rural Health Mission, Government of Madhya Pradesh, Bhopal, India.
authors.forename: Manohar
authors.initials: M
authors.lastname: Agnani
authors.affiliation: Faculty of Education, University of Hong Kong, Pokfulam, Hong Kong.
authors.forename: Alison
authors.initials: A
authors.lastname: Levin-Rector
authors.affiliation: Division of Global Health, Department of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden; RD Gardi Medical College, Ujjain, India; ayesha.de.costa@ki.se.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D001499:Bayes Theorem; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D005380:Financing, Government; D006801:Humans; D007194:India / Q000453:epidemiology; D008428:Maternal Mortality / Q000639:trends*; D008429:Maternal Welfare; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D015397:Program Evaluation; D012044:Regression Analysis; D012052:Reimbursement, Incentive / Q000191:economics*; D012423:Rural Health / Q000191:economics*
keywords: India; cash transfer; hospital delivery; maternal health