title: 'The money is important but all women anyway go to hospital for childbirth nowadays' - a qualitative exploration of why women participate in a conditional cash transfer program to promote institutional deliveries in Madhya Pradesh, India.
abstract: BACKGROUND
  In 2005-06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this.
  
  
  METHODS
  In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data.
  
  
  RESULTS
  Our findings suggest that women's increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for 'safe' and 'easy' delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women's choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities.
  
  
  CONCLUSIONS
  In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities.
authors.affiliation: Karolinska Institutet, Public Health Sciences, Tomtebodavägen 18, Stockholm, 171 77, Sweden. kristi.sidney@ki.se.
authors.forename: Kristi
authors.initials: K
authors.lastname: Sidney
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK. rachel.tolhurst@lstmed.ac.uk.
authors.forename: Rachel
authors.initials: R
authors.lastname: Tolhurst
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK. k.jehan@liverpool.ac.uk.
authors.forename: Kate
authors.initials: K
authors.lastname: Jehan
authors.affiliation: R. D. Gardi Medical College, Agar Road, Surasa, Ujjain, 456006, Madhya Pradesh, India. vishaldiwan@hotmail.com.
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.affiliation: Karolinska Institutet, Public Health Sciences, Tomtebodavägen 18, Stockholm, 171 77, Sweden. ayesha.de.costa@ki.se.|R. D. Gardi Medical College, Agar Road, Surasa, Ujjain, 456006, Madhya Pradesh, India. ayesha.de.costa@ki.se.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D000328:Adult; D002755:Choice Behavior; D036861:Delivery, Obstetric / Q000191:economics / Q000331:legislation & jurisprudence / Q000523:psychology*; D005260:Female; D005380:Financing, Government / Q000379:methods / Q000706:statistics & numerical data*; D006268:Health Facilities / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D036801:Parturition / Q000523:psychology*; D010342:Patient Acceptance of Health Care / Q000523:psychology; D010358:Patient Participation / Q000191:economics / Q000523:psychology*; D011247:Pregnancy; D036301:Qualitative Research; D012959:Socioeconomic Factors; D055815:Young Adult