Association for Public Policy Analysis & Management

Introduction: Most global maternal deaths occur in developing and lower middle income countries. These deaths can be avoided if mothers receive attention from skilled medical personnel during childbirth. Hence, the World Health Organization (WHO) recommends providing antenatal care to mothers and increasing the proportion of births at health facilities (institutional births) in developing nations.

India is a major contributor to the global burden of maternal deaths. It is a large, diverse, developing country in which certain states lag far behind others in terms proportion of institutional births. Further, some states have poorly equipped health facilities which deters mothers from delivering a child at such facilities. To remedy this situation, a combination of polices was recently implemented in India - the National Rural Health Mission (NRHM) which improved the conditions of healthcare facilities and the Janani Surkasha Yojana (JSY) which provided cash incentives conditional on giving birth at a health facility. Under each of these policies, greater policy attention was provided to a group of states that lagged behind the rest of the country in terms of maternal health outcomes.

Objective: I examine whether the rural areas of states that were targeted by policymakers had a significantly different change in the proportion of institutional births compared to the rest of the country and whether this change was associated with the conditions of the local health facilities.

Data and methods: I used data from two rounds of the India Human Development Survey (IHDS), which contained information about maternal health outcomes and about the conditions of the local health facilities available to mothers. Reproductive age women (between the ages 15 to 49 years) living in rural areas who had at least one childbirth in the five-year period prior to the survey interview were part of the sample (N=17,833). I employed difference-in-differences logistic regression models to investigate the change in the likelihood of having an institutional birth (birth at a health facility rather than at a mothers’ home) and in the likelihood of receiving appropriate antenatal care (having three or more antenatal visits) by mothers after implementing the NRHM and the JSY.

Results: Proportion of institutional births and of mothers receiving appropriate antenatal care in rural areas of targeted states increased at a significantly higher rate compared to other parts of the country. However, the change does not appear to be different between mothers who had access to better local health facilities compared to mothers that did not.

Conclusions: Targeting specific regions seems to have improved maternal health in India. However, better maternal health outcomes could have been the effect of factors such as improvements in socioeconomic conditions of mothers rather than actual policy provisions. Policymakers should carefully consider evidence from the current study and other reports which indicates major deficiencies in the health facilities available to pregnant mothers in India. Despite the recent progress in maternal health, improving the conditions of local health facilities available to mothers in developing countries is essential to reduce the global burden of maternal deaths.