India - Cash Payment Incentive For Hospital Births Helps Reduce Maternal Mortality
BRAMHA DASPUR, INDIA -- Urmila Rawat gave birth to her first two children in her thatched-roof home, as Indian village women have always done. Now eight months pregnant, Rawat assumed she would deliver her third baby at home as well.
By Emily Wax
Indian government officials see that traditional mind-set as an obstacle to the prosperity and health of a rising economic powerhouse that still has one of the world's worst rates of maternal mortality.
So the government decided to lure Rawat -- and millions of other village women -- to give birth in the cleaner, safer environment of a hospital with the most effective enticement it can think of: a cash payment of $30, or several weeks' wages for her farming family. And it seems to be working.
"The payment would be very helpful," said Rawat, 26, as she sat in the shade, her ankles swollen and her back aching. "We would use the money for food and clothes for the new baby."
India's high maternal mortality rate, while reduced by half in the past 20 years, remains a national embarrassment. Mothers dying in childbirth also create broken families that are an economic impediment.
India's rate of 254 deaths per 100,000 live births puts it in grim company. According to a recent report in the Lancet medical journal, more than half of all maternal deaths in 2008 were in just six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of Congo.
India's rate is about 10 times that of China, which has focused for decades on improving rural health care, according to the World Health Organization. The rate in some Indian states, including Rawat's home of Uttar Pradesh, is twice the national average, and in some areas, government statistics show that a woman dies in childbirth every hour.
Such dismal statistics, in a nation striving to be known more for technological innovation than for mothers dying preventable deaths on dirt floors, have spurred Prime Minister Manmohan Singh to promote the cash giveaway to mothers who deliver in hospitals.
It is just one aspect of a gargantuan effort to overhaul India's drastically uneven and overburdened health system and bring basic services to the most vulnerable of India's 1.2 billion people.
The WHO has ranked India 71st out of the 175 countries in the world in public health spending. Singh's government has promised to increase that from less than 1 percent of India's GDP to up to 3 percent by the end of this year. Health advocates say that's still just half the rate at which countries with comparable per capita incomes fund their health sectors.
Five years ago, Singh launched a National Rural Health Mission to revamp a rural health system lacking in equipment and trained health professionals. Still, a recent survey found that nearly 150,000 rural health centers do not have a doctor, according to India's health ministry.
Adding to the maternal mortality problem is a lack of properly trained midwives in rural areas. Skilled midwives who are based in villages have been one of the most important factors in dramatically decreasing maternal mortality in countries such as Sri Lanka and Thailand. India has several national programs underway to train more midwives.
Investing in women
The payment program seems to be working, according to Indian health workers and researchers who conducted the study for the Lancet.
"The cash payments mean that India is really starting to invest in women. That trickles out to the rest of the family and the rest of society," said Marie-Claire Mutanda, a health specialist with UNICEF, which is supporting the program.
In two of the poorest states in India -- Bihar and Uttar Pradesh -- the number of women giving birth in medical facilities soared from less than 20 percent in 2005 to nearly 50 percent in 2008, according to the most recent data available.
Doctors here attribute that to the payment program, whose Hindi name translates to "women protection scheme."
The government said it has no firm figures about the total number of women who have received cash or the total amount spent on the program, because it is administered by individual states. Under the plan, women receive a payment about two weeks after they deliver, and they are encouraged but not required to seek postnatal care.
In the wheat farming village of Bramha Daspur, there hasn't been a pregnancy-related death reported in two years.
Along with paying mothers to give birth in a clinic, India's government has hired an army of women, armed them with cellphones and notebooks, and given them training to become local health assistants, called Ashas, which means "hope" in Hindi.
The Ashas must have at least an eighth-grade education, an honest reputation in their village and a confident and assertive personality.
"Why don't you go to the hospital? Your sister did! Look at her healthy child," said Krishna Kumari, 36, an Asha who counseled Rawat in the shade of a mango tree one recent day.
Fanning herself in the heat, Rawat, already the mother of two children born at home, said she was afraid of going into the hospital and wasn't sure how her husband, an agricultural day laborer, would react to her spending $4 on a cab.
Kumari explained the reasons to go to the health center. It would be cleaner. There would be painkillers. And, of course, she'd get $30 -- which would more than cover the cab.
Rawat seemed convinced.
"Then it's decided. I will come for you when the labor starts," said Kumari, writing the due date in her notebook.
A lack of knowledge
Here in Uttar Pradesh, India's most populous state, a $30 payment often stands between life and death. For many farming families, that money is about three weeks' pay, sometimes more.
But the larger hurdle is often a deep lack of education in villages about how basic medical care can make a life-or-death difference in childbirth.
The Lancet study, conducted by University of Washington researchers and funded by the Bill & Melinda Gates Foundation, found that the poorest and least-educated women were least likely to take advantage of the government cash incentive.
In rural India, poor men often refuse to allow their wives to go to the hospital, and many women in this class-conscious society say they lack the confidence to enter a hospital.
"Before this system, we didn't have a hint of what to do," said Sangeeta Shukla, 26, who took Kumari's hand and thanked her for the payment while her 2-week-old daughter napped. "The hospital was very confusing. We weren't sure who to talk to or what we needed."
But although the cash-payment program has quadrupled the number of women going to health facilities, its success has further burdened an overloaded health system.
"The government is trying," said Ishwar Saran, the government's chief medical superintendent in Lucknow. "But the population makes the progress slow. If you create a government facility for 100 people, 200 show up."
On a recent sweltering afternoon, rows of pregnant women rested under spinning ceiling fans inside a government health clinic.
Each was accompanied by an Asha who held their hands, gave them water and rubbed their backs as labor pains grew stronger.
Watching the scene, K.P. Singh, a physician at the hospital, said he was proud.
"Childbirth is hard enough, even in the best circumstances," Singh said. "The payments and the Ashas have done wonders for India. But this is just a good beginning."