We observed that the institutional deliveries have increased after the implementation of JSY. Similar trends were observed in other studies indicating that the benefits of this scheme are being availed by a wider portion of the population (17
). The proportion of institutional deliveries in India was around 40% in 2005-2006, which continued to increase up to 72% in 2009 (11
). In the current study, almost 85% of the beneficiaries belonged to socially-disadvantaged class (scheduled caste, scheduled tribe, and other backward classes), which have been reported by other researchers also (20
). This could be explained by the fact that a large proportion of the populations in the state of Madhya Pradesh comprise these groups (15
) and also that JSY increased the hospital attendance among socially-disadvantaged classes. Madhya Pradesh is one of the low-performing states in India in terms of health indices, with a significant number of pregnancies occurring in women below 20 years of age. Pregnancy in early age poses high risk to the mother and, therefore, a significant increase in institutional deliveries among the women of this age-group can play a key role in reducing MMR and achieving MDG 5. We observed that there is an increase in institutional delivery among the illiterate and lower socioeconomic class covered by JSY, indicating that the scheme is reaching the target population which earlier preferred home deliveries due to lack of education and poverty. However, the proportion of the illiterate beneficiaries was still small compared to the total beneficiaries.
The significant increase in the number of rural pregnant women for institutional delivery can be attributed to the fact that low socioeconomic status and poverty of rural population deterred them from travelling a long distance and to spend money for delivery in the past. However, it appears that introduction of cash incentive under JSY has helped in overcoming the financial barrier and motivated them to come for institutional delivery (13
The finding that there was an increase in the absolute number of maternal deaths in the post-JSY period should be interpreted with caution. First, it was not a community-based study that reflected a complete picture. Second, the rise in maternal deaths in rural areas could be due to the fact that the study centre is a tertiary-level referral health facility, has a very large catchment area involving hundreds of villages, and more complicated cases from the rural areas were being referred to this facility at the last minute for lack of more skilled and sophisticated care. Thus, more pregnant mothers with high risks were referred to this hospital, and higher number of deaths occurred as only high-risk women were attending this facility. The same arguments hold good for increase in the morbidity among the study subjects in the post-JSY period. Late identification of the high-risk pregnancy cases, poor road connectivity, and poor availability of transportation further aggravated the problem by causing delay in referral (21
It was observed that most of the deliveries occurred in the age-group of 21-30 years, and similar finding has been reported by other authors also (22
). Statistically significant (p<0.01) increase in the institutional deliveries was also observed in the age-group of 31-40 years. Many of these women were coming for the first time to a health facility for delivery and this indicates that the motivators under this scheme were able to identify these high-risk mothers and referred them timely to a higher-level service centre (23
The higher maternal mortality among illiterate women, compared to higher-educated women, has also been reported by other author, clearly depicting a direct correlation of women's literacy with maternal mortality (24
). Our observation of the higher rate of maternal deaths among middle and lower-middle socioeconomic strata, compared to upper class, has been supported by other studies (23
). A significant increase in maternal deaths in lower-middle class and lower class could be explained by the fact that more and more families in these socioeconomic classes started opting for hospital deliveries because of increased awareness and the cash incentives given from JSY and, thus, started getting reported for mortality and morbidity.
This study noted eclampsia, pre-eclampsia, and anaemia as the most common underlying causes of maternal deaths. The high number of cases of eclampsia indicates poor antenatal care and poor and untimely referral. In this study, approximately three-fourths of all pregnant women were found to have some form of anaemia. It appears that the identification and referral of anaemia cases seem to have increased. Anaemia is a known major risk factor for maternal mortality, and high prevalence of anaemia in these women should also be seen as a reflection of the suboptimal quality of antenatal care services. However, the higher risk factors among the study subjects in post-JSY period can also be taken as an indication of effective functioning of the referral system.
Strengths and limitations of the study
This study was done in a tertiary-level hospital with a large catchment area and gives an opportunity to analyze a significant number of deliveries for mortality and morbidity pattern. However, this is not a community-based study and, hence, it is not possible to elicit the reasons why a large section of the people still does not prefer institutional deliveries and what their opinion regarding JSY was.
The JSY has increased the proportion of institutional deliveries in India, specifically among vulnerable populations. There are indications that the referral mechanism and other systems under this scheme are performing well, and it can be expected that the scheme will further increase institutional deliveries and contribute in reducing maternal mortality and bring health equity in the populations. There had been an increase in the reporting of maternal mortality and morbidity. Overall, institutional deliveries increased by 42.6% after implementation of JSY in the study institute. Anaemia was the most common morbidity factor observed in this study. There was a significant increase in cases of eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria after implementation of JSY. The scheme appeared to increase institutional delivery, which has the potential to reduce maternal morbidity and mortality, improve child survival and ensure equity in maternal healthcare in India. The lessons from this study and other available sources should be utilized to improve the performance of this scheme in India. Moreover, the high rate of anaemia among the study women demands immediate attention during the antenatal period. The long-term financial and social investment in women's literacy would definitely add to the benefits under JSY in India.