State and socio-demographic group variation in out-of-pocket expenditure, borrowings and Janani Suraksha Yojana (JSY) programme use for birth deliveries in India

BACKGROUND: High out-of-pocket-expenditure (OOPE) deters families from seeking skilled/institutional care. ‘Janani Suraksha Yojana (JSY), a conditional cash transfer programme launched in 2005 to mitigate OOPE and to promote institutional deliveries among the poor, is part of Government of India’s efforts to achieve Millennium Development Goals (MDGs) 4 and 5. The objective of this study is to estimate variations in OOPE for normal/caesarean-section deliveries, JSY-programme use and delivery associated borrowings - by states and union territories, and socio-demographic profiling of families, in India. METHODS: Secondary analysis of data from the District Level Household Survey (DLHS-3), 2007–08. Mean and median OOPE, percentage use of JSY and percentage of families needing to borrow money to pay for delivery associated expenditure was estimated for institutional and home deliveries. RESULTS: Half (52%) of all deliveries in India occurred at home in 2007/08. OOPE for women having institutional deliveries remained high, with considerable variation between states and union territories. Mean OOPE (SD) of a normal delivery in public and private institution respectively in India were Rs. 1,624 and Rs. 4,458 and for a caesarean-section it was Rs. 5,935 and Rs. 14,276 respectively. There was considerable state-level variation in use of the JSY programme for normal deliveries (15% nationally; ranging from 0% in Goa to 43% in Madhya Pradesh) and the percentage of families having to borrow money to pay for a caesarean-section in a private institution (47% nationally; ranging from 7% in Goa to 69% in Bihar). Increased literacy and wealth were associated with a higher likelihood of an institutional delivery, higher OOPE but no major variations in use of the JSY. CONCLUSIONS: Our study highlights the ongoing high OOPE and impoverishing impact of institutional care for deliveries in India. Supporting families in financial planning for maternity care, additional investment in the JSY programme and strengthening state level planning are required to increase the proportion of institutional deliveries.