Background
Methods
Study context
District #1 | District #2 | Madhya Pradesh | |
---|---|---|---|
Total Population (million) [19] | 2 | 1.1 | 72 |
Rural Population (%) [19] | 60 | 79 | 72 |
Female literacy (%) [19] | 64 | 65 | 68 |
Human Development Index (HDI) [59] | 0.626 | 0.564 | 0.375 |
Crude Birth Rate [21] | 24 | 24 | 25 |
Institutional delivery (%) [21] | 85 | 60 | 83 |
MMR [21] | 176 | 361 | 227 |
The Janani Suraksha Yojana program in Madhya Pradesh
Study participants
Characteristics of the study sample
n = 24 | Total | Public (JSY) | Private | Home |
---|---|---|---|---|
Age | ||||
19-24 | 16 | 6 | 2 | 8 |
25-36 | 8 | 5 | 1 | 2 |
Education | ||||
No/Primary Education | 12 | 6 | 1 | 5 |
Secondary & Higher | 12 | 5 | 2 | 5 |
Caste | ||||
Scheduled Caste | 5 | 1 | 0 | 4 |
Other Backward Caste | 12 | 7 | 2 | 3 |
Scheduled Tribe | 4 | 1 | 0 | 3 |
General | 3 | 2 | 1 | 0 |
Parity | ||||
Primi-parous | 6 | 3 | 1 | 2 |
Multi-parous | 18 | 8 | 2 | 8 |
Distance to EmOC Facility | ||||
Close to facility (<5 km) | 6 | 4 | 0 | 2 |
Far from facility (>5 km) | 18 | 10 | 3 | 5 |
Study instruments and data collection
Analysis
Ethical considerations and approvals
Results
Main Theme #1 | |||
Institutional delivery is now the social norm | |||
Sub-theme
|
1.1 Social norm to deliver in
a health facility
|
1.2 Individual women’s perception
of the importance for ‘safe’ and
‘easy’ delivery
|
1.3 Social pressure from the ASHA
to deliver in a health facility
|
Codes
| Desired place of delivery · Justification for place of delivery · Affirmation of normalcy · Reflections on future delivery plans · Comparison between home delivery and institutional delivery · Advantages/disadvantages of home delivery and institutional delivery · ASHA involvement · Dai involvement · Anganwadi helper involvement · Sweeper involvement · How decision where to deliver is made · Who influenced · Role of Family members on where to deliver · Family relationships · Affirmation of normalcy · Reflections on future delivery plans · Perceptions of quality of care | ||
Main Theme #2 | |||
Role of cash incentive: Diversity among views | |||
Sub-theme
|
2.4 Incentive motivates for
institutional delivery
|
2.5 Money is important but health
is more important
|
2.6 Institutional delivery regardless
of the cash benefit
|
2.4.1 Difficulties to retain entire benefit and
unintentional costs associated with
participating in JSY
| |||
Codes
| Influence of JSY on place of delivery · Reflections on future delivery plans · Justification for place of delivery · Awareness/View of JSY program · Expenses related to hospital delivery · Rationale for giving payments · Perception of delivery costs · Influence of JSY on place of delivery · Perception how the incentive should be spent · Adequacy of Incentive · Process/procedure to obtain incentive Actual use of incentive payment · ASHA involvement · Method of payment for delivery | ||
Main Theme #3 | |||
Unintentional participation due to barriers to institutional delivery | |||
Sub-theme
|
3.7 Circumstantial events and difficulties with transportation cause unintentional non-participation.
| ||
Codes
| Pre-labor/labor experience · Transport experience · Role of transport in determining place of delivery · How decision is made · Role of Family members · Family relationships · ASHA involvement · Dai involvement · Role of Family members on where to deliver | ||
Main Theme #4 | |||
Public hospital is acceptable for ‘normal’ delivery but not complicated | |||
Sub-theme
|
4.8 Distrust in public delivery services
| ||
Codes
| Trust/distrust in public sector to provide care · Trust/distrust in private sector to provide care · Comparison of sectors |
Institutional delivery is now the social norm (Main theme #1)
Social norm to deliver in a health facility
“I had decided to go to the hospital from the beginning [of my 4th pregnancy]. For the first three babies, I delivered at home. [For this one] I didn’t want to deliver at home. Nobody delivers at home now. All women go to the hospital…” – District 1 JSY Participant, Age 30“Everyone in our village goes to the [public] hospital, that’s why I also went there.” – District 1 JSY Participant, Age 20
“Women have started changing their decision to deliver at home. Earlier women never thought like this. … People have started thinking that we should go to the hospital for better facilities and free delivery. There is risk in delivering at home.You can’t get good treatment at home. If some women require blood during delivery, it is not available in village.... So, now women are aware and they want to go to hospital for delivery.” – District 2 JSY Participant, Age 23
Individual women’s perception of the importance for ‘safe’ and ‘easy’ delivery
Social pressure from the ASHA to participate in JSY
“I became angry because she [ASHA] was scolding me…[ASHA said] You should have informed me and now hospital officials will say that I did not bring you in time. Delivery cannot happen so fast…”– District 1 Home Delivery, Age 21
Role of the cash incentive: ambivalence towards the perception and influence of the incentive (Main theme #2)
“I always wanted to deliver in the hospital as I will get money. But I was unable to go to hospital for delivery. I was in field harvesting crops during this delivery and suddenly the baby came out. What could I do? … I thought that it would have been better if I delivered in hospital because in hospital we get the money… At home you get nothing.” – District 2 Non-JSY Participant (Home delivery), Age 30
“[I wanted to deliver my baby] in the hospital but previously thought to deliver at home because at the hospital the nurse … will take money (Rs.200, $3.33) so it becomes a problem. Now in the hospital, we get money for delivery … we will get money to help pay for all the expense but not at home.” District 2 Non-JSY Participant (Home delivery), Age 23
“We will go to the hospital even if we don’t get the money because we go to the hospital for better health and good treatment. Not for the money. If we die without good treatment, what we will do with the money?” – District 1, Age 28
Why do women not participate in the program?
Unintentional non-participation due to barriers to institutional delivery (Main theme #3)
“I never decided to deliver at home. But it is difficult to reach hospital at night as my husband was not at home … I decided that if there is pain during the day I would go to hospital but if pain is there at night I would do it at home. During the day I can go alone or call ASHA worker. But at night who will run and call ASHA or the vehicle? – District 2 Non-JSY Participant (Home Delivery), Age 22
“I planned to deliver in the hospital…When the pain started it was raining heavily. When I told my parents about the pain, they called the [free emergency transport] vehicle but they were not able to get through because of the heavy rains…We were planning to go to the hospital but the baby came out very quickly.” – District 2 Non-JSY Participant (Home Delivery), Age 22
Public hospital is acceptable for ‘normal’ delivery but not complicated (Main theme #4)
“We will go to [public] hospital but if I feel very weak, I will go to the [private] facility.” – District 1 JSY Participant, Age 20