Cash Transfers, Institutional Delivery and Quality of Care in India

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By: KG Santhya, Associate, Population Council, New Delhi

This post is part of a series of posts on cash transfers and maternal health. To read other posts in the series, click here. If CCTs are a part of your work or research, we’d love to hear from you. Contact us at if you are interested in writing a guest post on the topic.

Today, in India, nine out of 10 pregnant women receive at least one antenatal check-up; three out of four deliver their babies in a health facility; and three out of five mothers receive a postpartum check-up within 10 days of delivery. Indeed, a remarkable achievement for a country that has struggled for decades – and continues to struggle – to make motherhood safe for its women. A major driver behind this surge is the Janani Suraksha Yojana.

It is very heartening to see that millions of women are accessing maternal health services. But, how are they treated at the facility once they arrive for these services? Simply as numbers to be recorded in facility registers or as human beings endowed with the right to health? Have we short-changed quality for the sake of quantity? These were some of the questions that loomed large in our mind when we set out to talk to women who had recently delivered in two districts of the state of Rajasthan, a state where 388 maternal deaths take place for every 100,000 births. We conducted a survey and talked with nearly 5,000 women. The experiences of many suggest that the quality of care is unacceptably poor.

Did the introduction of the JSY lead to this unacceptably poor quality of care received by women in our study? To answer this question, we compared the experiences of women who had delivered both before and after the JSY was introduced; their descriptions of experiences at the time of their two deliveries portray a mixed picture.

Dhapu, a 24 year old mother of two children living in a town, was very unhappy with the introduction of the JSY; for her, the quality of care has indeed worsened “The condition has worsened; we have to wait for half-an-hour to see the doctor and then, the doctor gives you just five minutes.”

Rekha, a 25 year old mother of 2 children living in a village, had diametrically opposite views; for her, the situation has improved remarkably “Of course, there is improvement in the health of mothers as well as that of children. Earlier, people were not so aware (about institutional delivery) and many deliveries in the village used to take place at home, attended only by traditional birth attendants. There used to be problems; for example, there were problems in cutting the umbilical cord, and also some children used to turn blue or die; but now, if they face any problem in the hospital, they can be checked and treated promptly. Earlier, in villages, ladies had to bear pain for many days if a problem occurred during delivery, and some mothers used to die; it doesn’t happen in the hospital as they go for an operation in case labour pain is prolonged. Earlier, we had to go to the hospital on our own and as we didn’t know the doctors, they didn’t take care of us properly; now, as the ASHA accompanies us to the hospital, doctors also talk properly and treat us properly. Before, we had to spend money from our own pockets, now we get Rs.1,400 from the scheme and we can at least pay the conveyance charges and purchase medicines etc. using that money.”

For women, like Kamla, a 28 year old mother of four children, the poor quality of care received by them had nothing to do with the introduction of the JSY. It was the reality of their life before the JSY was introduced and continues to be the reality today as well: “Each time, I must have waited for at least half-an-hour to 45 minutes. When the nurse came, she gave me dard badane ka injection [for increasing the pain]. She didn’t check my temperature or pulse. Neither did she do any abdominal or vaginal examination… She pressed my stomach so heavily that I screamed. It was like this for all my four deliveries.”

Kamla wasn’t an exception; women like her constituted the majority. Our survey findings documented that the JSY has led to improvements in a few aspects of the quality of maternal health care, but for most aspects, has had no effect on the quality of care, For example, the health care provider did not conduct essential examinations – abdominal examination, vaginal examination, checking temperature and pulse – for about three in four women when they were admitted to the hospital for delivery at both times, that is, before and after the JSY was introduced. Many women were subjected to harmful practices at both times. For example, the health care provider applied strong fundal pressure (pushed hard on the abdomen) on one in three women before they delivered; they gave injection for increasing labour pain (most likely oxytocin, a practice that can sometimes lead to perineal tears, uterine rupture and foetal distress). A few things, however, have improved with the introduction of the JSY. Women, by and large, are discharged from the facility after delivery much later than in the pre-JSY period and are allowed to have the person accompanying them — family member, ASHA for example – to remain with them during delivery.

In short, while the JSY has succeeded in bringing women to the health facility and has neither compromised the quality nor improved it, there is a long way to go to make motherhood safe and the quality of maternal health services respectful for women in India. The same vigour that we have shown in getting women to the facility should be demonstrated in ensuring that they receive quality care, including the benefits of evidence-based best practices, once they reach it.