title: Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India.
abstract: BACKGROUND
  High out-of-pocket expenditures (OOPE) make delivery care difficult to access for a large proportion of India's population. Given that home deliveries increase the risk of maternal mortality, in 2005 the Indian Government implemented the Janani Suraksha Yojana (JSY) program to incentivize poor women to deliver in public health facilities by providing a cash transfer upon discharge. We study the OOPE among JSY beneficiaries and women who deliver at home, and predictors of OOPE in two districts of Madhya Pradesh.
  
  
  METHODS
  September 2013 to April 2015 a cross-sectional community-based survey was performed. All recently delivered women were interviewed to elicit delivery costs, socio-demographic characteristics and delivery related information.
  
  
  RESULTS
  Most women (n = 1995, 84 %) delivered in JSY public health facility, the remaining 16 % (n = 386) delivered at home. Women who delivered under JSY program had a higher median, IQR OOPE ($8, 3-18) compared to home ($6, 2-13). Among JSY beneficiaries, poorest women had twice net gain ($20) versus wealthiest ($10) post cash transfer. Informal payments (64 %) and food/baby items (77 %) were the two most common sources of OOPE. OOPE made among JSY beneficiaries was pro-poor: poorer women made proportionally less expenditures compared to wealthier women. In an adjusted model, delivering in a JSY public facility increased odds of incurring expenditures (OR: 1.58, 95 % CI: 1.11-2.25) but at the same time to a 16 % (95 % CI: 0.73-0.96) decrease in the amount paid compared to home deliveries.
  
  
  CONCLUSIONS
  OOPE is prevalent among JSY beneficiaries as well in home deliveries. In JSY, OOPE varies by income quintile: wealthier quintiles pay more OOPE. However the cash incentive is adequate enough to provide a net gain for all quintiles. OOPE was largely due to indirect costs and not direct medical payments. The program seems to be effective in providing financial protection for the most vulnerable groups.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden. Kristi.sidney@ki.se.
authors.forename: Kristi
authors.initials: K
authors.lastname: Sidney
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.
authors.forename: Mariano
authors.initials: M
authors.lastname: Salazar
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Marrone
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.|Public Health and Environment, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India.|International Center for Health Research, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India.
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.|International Center for Health Research, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India.
authors.forename: Ayesha
authors.initials: A
authors.lastname: DeCosta
authors.affiliation: Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Lindholm
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D017048:Health Care Costs / Q000592:standards*; D005102:Health Expenditures / Q000592:standards*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D007194:India / Q000453:epidemiology; D008427:Maternal Health Services / Q000191:economics*; D036801:Parturition; D011247:Pregnancy
keywords: Conditional cash transfer; Facility based delivery; India; Maternal health; Out-of-pocket expenditure