Current Status of Maternal and Infant Health in India

Pregnancy and motherhood are natural processes that bring many positive changes in the life of a woman. However, many women end up suffering a lot during pregnancy because of complications like preecmplasia, haeomorhage, unsafe abortion and infection. This continues in the post-partum period and such issues occur mainly because of poor access to quality maternal care (Mousumi, 2015). Improving maternal health and reducing maternal deaths is one of the human rights challenges in middle and low income countries which has attracted attention of many policy makers (Ram Jat, 2014).

India is also among the middle income countries which is struggling to deal with huge toll of maternal deaths. According to Nair and Panda (2011), out of 5,36,000 maternal deaths worldwide every year, India accounted for 11,700 deaths in 2005.  However, with the introduction of public health initiative in the last two to three decades, a recent report suggests a decline in maternal mortality rate. The report by O’Neil, Naeve and Ved (2017) revealed a decline in maternal mortality ratio from 892 maternal deaths/100, 000 live births in 1972-1976 to 178/10, 000 live births in 2010-2012. Despite this achievement, India is still short of the millennium development goal (MDG) target of reducing maternal deaths to 109 maternal deaths/ 100, 000 live births (Travasso, 2015).

In addition, due to the issue of poor maternal outcomes, the ultimate negative impact has been found on health of neonates and infants. Sankar et al. (2016) explains that 0.75 million neonates dies every year in India, which is highest for any country in the world. Although the  rate of  neonatal mortality rate has reduced from 52 per 1000 live births in 1990 compared to 28 per 1000 live births in 2013, rate of decline is slow for infant and under-five children. Hence, improve figures of infant mortality rate also needs to be prioritized.

Although many policies and initiatives have resulted in reducing the rate of maternal maternity ratio (MMR) and improving infant development outcomes, the rate of improvement has been very slow. Some of the issues that limit the delivery of quality maternal care in India include poor adherence to clinical guidelines, lack of patient centered care and inequitable delivery of care because of disproportionate distribution of facilities in urban settings (Joshi, 2013,

June). Some of the policies and programs that paid attention to child and maternal health included the Safe Motherhood Scheme (Janani Suraksha Yojna program), the National Rural Health Mission (NRHM), immunization programs and many others. However, the improvement in mortality rate and health of mothers has not yet achieved the desired standard compared to other BRIC (Brazil, Russia, India and China) countries (Nair & Panda, 2011). To understand the reason behind this trend, there is a need to analyze how policies related to maternal and child health has fared in India. This would help to understand whether the health care system is currently prepared to meet the key objectives of the policy or not.

Challenges in Delivering Quality Maternal Care in India

The main purpose of this research is to conduct a systematic review of research literatures to analyze the impact of policies on infant and maternal health in India. Systematic review method will help to critically evaluate policy initiatives related to maternal and infant health and understand their success or failures in terms of outcome achieved. Another rationale behind conducting systematic review is that it will to critically explore all policies implemented for maternal care in India and find out the strength and weakness of the policies in achieving desired maternal mortality rate target.

The main objective of the systematic review is to evaluate the outcomes of the policy initiatives and find out specific barriers or facilitators that influenced the outcome. It also aims to recommend suggestions to improve health care system by looking at barriers experienced while implementing policies related to maternal health. The PRISMA framework has been applied to conduct and present the outcomes of the selected research papers.

Past research papers have highlighted the challenges associated with providing quality maternal care in India. Vora et al. (2009) gave evidence regarding the reason behind lower maternity rate in India despite several programmatic efforts and rapid economic progress in the country. The data related to current trends in maternal health was collected by Vora et al. (2009) from review of literature (published and unpublished reports of government and non-government agencies), interview with stakeholders and secondary analysis of data from national programs. The Safe motherhood program strategies and implementation was also analyzed to evaluate maternal health in India.

The research findings revealed a decline in MMR related to a decrease in incidence of malaria in pregnant women. In addition, most of the maternal deaths in India occurred because of post partum haemorrhage. The report suggested that instutional deliveries have increased in India. However, postnatal care remains neglected as very few women visit a maternal clinic after the first week of delivery. According to World Health Organization, postnatal period is a critical period for mothers and babies where utmost care is needed to prevent maternal and infant deaths. However, this remains the most neglected period for quality care provisions (World Health Organization, 2013).

Hence, Vora et al. (2009) highlighted the importance of increasing postnatal care for pregnant women. However, the gap in the research by Vora et al. (2009) is that it did not mentioned whether the SAFE motherhood programme took any steps to improve the quality of post natal care or not. This makes detailed analysis of the safe motherhood programme necessary.

Review of Past Research Papers on Maternal and Infant Health in India

The research paper by Vora et al. (2009) also described the reason behind poor maternal health. The study revealed the impact of education and economic status of women as the reason behind poor access to maternal care. Considering the causal effect of education on maternal health outcome is vital, Weitzman (2017) revealed that increasing women’s level of education can decrease the rate of short birth intervals, unwanted pregnancy and an increase in the use of antenatal care.

 Hence, finding presented by Vora et al. (2009) is significant as it highlights areas which have remained neglected in maternal health improvement initiative in India. It also specified limitations of the SAFE motherhood program as giving more priority to immunization and antenatal care affected emergency services. This occurred because fixed day scheduling of work lead to more focus on routine preventive task and ignorance of emergency services.

Overall, the analysis of the study findings revealed that maternal care programs were implemented to strengthen the delivery of care to nurses. Nurses can play a role in entering into partnership with medical team and bringing changes in maternal health services (Bernstein et al., 2017). However, lack of managerial capacity and clear overall program objectives affected the outcome of the programme (Popescu & Predescu, 2016). As this study gave a brief idea of several initiatives, there is a need to review those studies that evaluates single maternal care policy initiatives to get better idea about flaws in their program planning and delivery process.

Past research evidence has also highlighted the barriers to safe motherhood in India. Reviewing this evidence and comparing it with the activities of different maternal care programs would help to understand whether these barriers have been considered during program planning and implementation or not. Maternal mortality is a negative indicator of women’s status of India and as India’s current level remains unacceptable, Singh et al. (2009) aimed to highlight current status about maternal health in India and highlight trends related to the gap in access to maternal health services.

The study revealed the decline in fertility has reduced risk of maternal death. However, it is far away from the Millennium Development Goal of reducing the MMR by three-quarters in 2015 compared to 1990 (Travasso, 2015). This was explained because of the impact of socioeconomic and cultural variations on the access to care. This link was observed by sharp decline in maternal mortality rate in northern and southern states of India. For example, northern states like Assam accounted for two-third of all maternal deaths in India, whereas southern states contribute to only 10% of the maternal death. This difference in MMR was also attributed to difference in educational attainment of women in north and south Indian states. In addition, poverty was also found to increase the likelihood of maternal death because of women’s inability to obtain prenatal and delivery care.

Barriers to Safe Motherhood in India

This is consistent with the research by Wickham, Barr and Taylor-Robinson (2016) which proved that moving into poverty increase the odds of maternal psychological distress and behavioral problems in children. Singh et al. (2009) also revealed that unplanned childbearing and high-risk birth related to maternal age is a factor contributing to high MMR. Hence, this evidence suggest that socio-economic variables plays a vital role in women’s  access to maternal care and utilizing maternal health programs to educate women about the importance of prenatal care and referral to appropriate facilities during labor is important. The effectiveness of programs like JSY (Janani Suraksha Yojana)and NRHM (National Rural Health Mission) particularly in increasing institutional delivery particularly in states like Uttar Pradesh and Bihar needs to be monitored.

The significance of the research by Aggarwal, Kumar and Kumar (2003) is that it highlighted the challenges faced by pregnant women living in hilly terrains of India. This research was done after finding high incidence of neonatal deaths compared to infant deaths in India. This also brings the question whether obstetricians in India are not skilled enough to recognize and manage neonatal complication. By the investigation of early neonatal deaths and cause of such deaths in four districts of Himachal Pradesh, it was found that in 84% of infant related death cases, there was no health facility in the village and the government based hospital was accessible at more than 2-hours in 49% cases.

Another significant finding was that about 87% of the participants had to use foot to come to travel by foot to access road and access transport options like bus and motorized transport. Another vital finding was that in all neonatal death cases, only 4% cases were found where health care providers warned pregnant women regarding the possibility of complications during the delivery or the post-partum period. This evidence indicates that rural and district areas in India lack appropriate facilities to take care of premature babies. It also reflected lack of experience of health care professionals in dealing with complications.

This evidence provides guidance to find out whether maternal health programmes in India have considered the issue of neonatal death and distance issues during delivery of maternal care service or not. Hence, the gaps and challenges found in relation to maternal delivery trends in India suggest the need to critically evaluate individual programs and find out whether they have been effectively implemented to address diverse concerns related to access to maternal deaths.

Conclusion

Aim and objectives: 

The main aim of the research is to conduct a systematic review of research literature and critically evaluate impact of policies on infant and maternal health in India. By obtaining relevant articles related to the research aim, the main objectives of this research are as follows:

• To analyze policies implemented in India associated with improving maternal and infant health and the promotion of maternal care
• To evaluate outcomes of each policy in relation to maternal health parameters like reduction in MMR, rate of institutional delivery, access of antenatal services and early recognition of complications
• To analyze the credibility of research papers in terms of methodological rigor and consideration of biases in study
• To critically reflect on the strength and weakness of the policies and the method of implementation
• To find out gaps in current policy initiative implemented to improve maternal health
• To recommend future actions to fulfill unmet needs of pregnant women in India

Research design:

  A systematic review methodology was undertaken as part of the research design which is relevant to the purpose of research as it provides credible evidence on the effectiveness of maternal health polices in India. A systematic review involves a rigorous process of assessment of research studies and evaluates the effectiveness of treatment on targeted populations. By bringing together results of separate studies related to the research question, systematic reviews can give an insight into the overall effectiveness of the intervention (Boland, Cherry & Dickson, 2017).

Another advantage of taking systematic approach as a method of investigation is that is the most reliable source of evidence, and can be used to guide clinical practice and implement evidence based care (Petticrew, 2015). Hence, policy makers and health care administrators are provided with the opportunity to identify the best steps needed to achieve reduction in MMR and apply the evidence to enhance the maternal health status of women in India.

To retrieve articles the evaluating the impact of different policies on maternal health in India, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines has been followed to conduct the systematic review. The PRISMA checklist is an evidence based protocol to report about different studies and interventions. There are 26 items contained within the PRISMA checklist which need to be included in each section such as introduction, method, results and discussion.

It is a well-described protocol that facilitates development of a robust systematic review. Following a validated research protocol also increases the transparency of the research process and the reliability of the data obtained (Moher et al., 2015). For this reason, PRISMA guideline has been followed to strengthen the methodological quality and reliability of completed systematic review.

Search strategy:

The search for article has been done by first developing eligibility criteria for the inclusion of research papers. The advantage of framing the eligibility criteria is that it allows for screening of research articles based on certain criteria and boundaries. The inclusion and exclusion criteria for selecting research papers related to the research question were as follows:

Intervention: Only those articles were included in the systematic review which investigated policy or policies related to maternal and infant health in India. These could include maternal health program or initiatives implemented by the Indian Government.

Population: Research papers which focused on Indian women, new born and/or infants were included in the systematic review.

Context or setting: Articles must investigate policies that have been implemented in health care setting or states of India.

Publication: Only those research papers were included which has been published between the year 2008 to 2018.

Language: Only research papers that were published in English were included in the review

Type of research design: The selection of research papers were not restricted by any particular research design. All research papers which were associated with the impact of policies on maternal health in India were included.

According to the PRISMA checklist, the next phase after framing the research question is to give overview of all information sources from where articles will be retrieved. To find research articles that can address the research question, it was decided to access those databases that publish research in the field of health and bioscience. With this perspective, databases such as MEDLINE, CINAHL and PubMed were used to search for relevant articles. The main rationale for including databases is that all refer to high quality search articles that have been published in peer reviewed journals from across the world (McCall, 2014).

Hence, papers were retrieved from the above mentioned databases. The search strategy is a comprehensive process and the success of the search process depends on use of appropriate search terms and search strategy for individual databases (Gough, Oliver & Thomas, 2017). The keywords that were used in the search across all three databases included ‘maternal health policy’, ‘maternal health in India’ and ‘maternity policy in India’. Apart from these search terms and search phrases, certain search limits such as language and publication date was applied to ensure that eligible research papers are retrieved.

As per the PRISMA protocol for reporting about systematic reviews, this section also provided comprehensive detail regarding search strategy for conducting search in CINAHL database. The main advantage of conducting search in CINAHL is that it has both basic and advanced search options (Wright, Golder & Lewis-Light, 2015). Hence, when articles cannot be retrieved by the use of primary search terms or phrases mentioned above, the advanced search option was used to conduct paper search.

The main feature of advanced search filter in CINAHL database is that boolean operators like ‘AND’ and ‘OR’ can be applied to make the research process more explicit. Karimi et al. (2014) explains that the information seeking task requires boolean search methods and it can improve the overall search performance. It also increases the credibility of the work as oolean retrieval method divides a search space on the basis of eligibility criteria and combining string of keywords with Boolean operators enhanced the proficiency of the search process (McGowan et al., 2016).

The key words were developed after identification of primary search terms and using thesaurus to identify words with similar meanings. This helped to develop many important search terms for the review. The search term were identified by first defining PICO (Population, Intervention, Comparator and Outcome) element for the research topic. The list of search terms developed for the search in the CINAHL databases are as follows:

Table 1: Process of developing search terms for databases

Pico elements	Keywords	Search terms
Patient or Population (P)	Indian women or infants	Pregnant women/ women in India/ infants or newborn
Intervention (I)	Maternal health policies	Maternal health programs/maternal care initiative/ maternal and infant care program
Comparison/ Context (C)	Health care facilities	Private clinics/antenatal clinics/antenatal services
Outcome (O)	MMR	Maternal mortality rate/ maternal complications
Infant mortality	Infant health/ infant outcome

After the development of list of keywords, boolean operators such as ‘AND’ and ‘OR’ were applied. ‘AND’ was used between search terms to narrow the search process and retrieved only those articles which had both the key terms mentioned. In addition, ‘OR’ was used to expand the search process and increase the possibility of retrieving those articles which has either of the search terms. Hence, use of OR helped to retrieve more number of related articles (Bramer, Giustini & Kramer, 2016). The below mentioned table gives a brief idea about how the search terms were combined with boolean operators to retrieved research literatures:

Table 2: Process used to combine search terms with Boolean operators:

Sl. No.	Search terms of phrases	Boolean operator	Search terms of phrases	Boolean operators	Search terms of phrases
1.	Maternal care policies	AND	Maternal health  outcome OR MMR OR Reduction in maternal mortality rate	AND	India OR Rural India OR Urban India
2.	Maternal health initiatives                OR Maternal health programs
3.	(Name of specific maternal policy)             OR             Similar terms

Data collection:

The final set of research papers were selected based on rigorous process of identification, screening, eligibility and inclusion of research papers in the study. The identification of an article was accomplished by entering search terms and screening articles based on inclusion and exclusion criteria. The initial strategy during the eligibility phase was to review the title and abstract of the articles (Shamseer et al., 2015). To further confirm the relevance of the selected research papers, the full text article of the paper was analyzed to identify the full detail of outcomes of policy outcomes are discussed or whether only descriptive overview was provided. 

This process helped to confirm the final list of research papers that would be included in the systematic review. The number of records obtained after the database searching, the number of articles screened and number of articles assessed for eligibility are provided in the PRISMA flow diagram (Appendix 2). The main advantage of using a PRISMA flow diagram is that it can give a quick overview of the number of papers which were initially identified and the number of articles finally selected for the review based on the search process (Stewart et al., 2015). The format for the PRISMA flow diagram which is used in the results section is given in Appendix 1.

Data extraction is also the most vital part of a systematic review and approach taken to highlight the most important part of research paper makes the research presentation clear and useful (Moons et al., 2014). For the purpose of this systematic review, the following items have been summarized in the data extraction table (Appendix III):

• Author and year
• Research aim
• Policy discussed
• Outcome of the policy
• Strength and weakness
• Implications of the work

By going through the summary table, brief idea regarding the important elements presented in a single study can be understood.

Data analysis:

As this research aims to identify the role of maternal policies on child and maternal health India, it is evident that the systematic review is being done to evaluate changes found in the maternal health care system in India post policy implementation. Hence, thematic analysis has been undertaken as a method of analysis as this would help to identify common themes from qualitative data and use them to identify or interpret experiences of perceptions related to participation in a phenomenon (Braun, Clarke & Terry, 2014). As quality is also important to confirm the credibility and reliability of the work, the critical appraisal was done by review of considerations to reduce bias in studies, methodological rigor, sample size and recruitment process. This process helped to categorize whether the research is of high, low or medium quality.

Results: 

Based on the use of key words to search for literatures in the three databases, a total of 105 articles were identified. Out of these research articles, the 15 articles were removed as they were duplicates or almost similar studies. The remaining 80 articles were screened as per the inclusion and exclusion criteria. Based on the review of full-text articles, 8 were found suitable for inclusion in the study. The screening and reporting process has been conducted based on PRISMA guideline and the PRISMA diagram for the screening and eligibility process can be found in Appendix II.

Different research methods were used in the 8 articles selected for the research analysis process. Two papers were descriptive observational study. Retrospective analysis by means of mixed method study and several quantitative analysis method was also implemented to gain idea about the impact of different policies on maternal health. The key policies or government based initiatives that has been analyzed in the eight papers include NRHM (National Rural Health MIssion), ICDS (Integrated Child Development Scheme) and JSY (Janani Suraksha Yojana).  A brief overview of each paper is given in appendix III.

The systematic review and analysis of research papers gave rise to fouee themes. These themes are relevant to the research objectives and highlight the role of maternal health policy on MMR, rate of institutional delivery, access of antenatal services and early recognition of complications. The thematic analysis also gives an insight into the strength and weakness of each policy in terms of impact and method of implementation.

Theme 1: Impact of maternal policies on institutional delivery rate and MMR:

Out of eight articles, there were four articles that reported on the impact of maternal policies on institutional child delivery rate. Papers 1, 2, 3 and 8 reported on the stable increase of institutional delivery rates post the implementation of JSY scheme in India. Papers by (Gupta et al. 2012) Paper 1 and (Khan, Hazra and Bhatnagar 2010) paper discussed the impact of JSY particularly in the state of Madhya Pradesh and rural Uttar Pradesh respectively. However, paper 2 gave an insight into impact of rate of institutional delivery and maternal maternity rate across India. Paper 3 finding is considered a high quality evidence retrospective cohort based study which looked at increasing the reliability of the program evaluation process (Campbell & Stanley, 2015).

Cohort based study are more generalizable as it give an overview of the state of maternal health in all types of region. The common findings from the paper 1 and paper 2 is that both studies highlighted t the same gaps in JSY scheme suggesting that the program  focused too much on increasing institution delivery. However, no steps were taken to upgrade antenatal care. It revealed lack of skills of professional in increasing awareness about maternal health.

The strength of paper 3 is that by showing positive effect of incorporating counseling element in the JSY program, Khan, Hazra and Bhatnagar (2010) revealed that JSY has the potential to improve other behaviors such as early breastfeeding, post natal care, timely referral and delivery by skilled personnel. The gives implication for upgrading infrastructural arrangements so that ASHA (Accredited Social Health Activist) program could visit home of women and provide necessary education to prevent infant death (Bills et al., 2018).

Theme 2: Impact of maternal policies on reducing financial stress in families:

Maternal health policies in India mainly targeted improving the rate of hospital delivery so that pregnancy complications and poor antenatal outcomes could be avoided. There were two papers that specifically targeted the reduction of financial barriers to maternal health in India. Paper 4 (Angadi, Davalgi and Raghavendra 2017) highlighted about the role of several maternity benefit schemes like Madilu Yojana, Thayi Bhagya schemes and Prasuthi Araike Yojana schemes on improving financial and geographical access to quality care for poor women.

Working on this issue was important because Vail et al. (2018) revealed structural barriers such as poverty and logistical barriers such as inadequate labour facilities and human resource shortage as some of the cause behind poor maternal and infant health outcomes. Paper 4 revealed JSY as to be the service with the highest utilization rate and the main determinants of such high utilization rate included literacy of mothers, husband and families and belonging to above poverty line. In addition, there were also groups which did not utilized the services and major reason behind non-utilization was lack of awareness about scheme.

Hence, the paper 4 was able to highlight the gap in the cash incentive scheme which was that the program could not reach out to desired audience. To achieve the MDG target, it was necessary to focus on socioeconomic barriers to antenatal care and visits. Paper 5 by Sidneyet al. (2012) highlighted about the strength or weakness of the implementation process. For example, JSY was found to provide cash benefits on a timely basis. However, the possibility of introducing home visit to educate women was identified.

Theme 3: Impact of policies on reducing inequities in maternal care

There were two papers that reported about reducing inequities in maternal care. This included paper 7 (Rao and Kaul 2018) and 8 (Vellakkal et al. 2017). Paper 7 indicates about impact ICDS scheme on addressing equity issues in maternal care. The main advantage of ICDS was that it particularly targeted the problem of malnutrition and poor learning outcomes in children below 5 years. The study reported positive development of the ICDS scheme on increasing supplementary food provisions in infant. However, challenges in the implementation of the program suggested need for reforming the implementation process. The paper 8 is significant as it particular aimed to evaluated NRHM on reducing inequities in maternal health.

Women from low socioeconomic background living in deprived Indian states were targeted. The significance of the research methodology is that all types of index of inequality such as maternal age, rural-urban and caste was considered. The benefit of NRHM was seen by means of increase in uptake of institutional delivery. Hence, the study revealed that by increasing coverage of maternal care programs, inequity related issues can be addressed. However, some discrepancy in NRHM scheme is that inter-state variations were found because of difference in quality of health services and skills of ASHAs in each village. These factors need to be considered in future.

Theme 4: Impact on access to antenatal care in India

The paper 1, 2, 3 and 8 highlighted about the role of maternal policy and initiatives on increasing access to antenatal care. These improvements were achieved by motivating people to join the program through cash benefit schemes and integration of services in rural areas. This indicates the application of health belief model of changes as people’s belief and thinking related to antenatal care was changed by means of cash incentives (Skinner, Tiro & Champion, 2015). However, wider impact could not be achieved as vital aspects such as increasing knowledge and awareness was ignored.

Upon conducting a systematic review of scholar literature, with the aim of assessing the effects of different policies on maternal and infant health in India, four primary themes namely, (1) Impact of maternal policies on institutional delivery rate and MMR, (2) Impact of maternal policies on reducing financial stress in families, (3) Impact of policies on reducing inequities in maternal care, and (4) Impact on access to antenatal care in India, were identified. It was found that recent advancements have been made in order to improve different quality aspects of maternal health in the public healthcare system of India. This chapter will present a detailed discussion of the identified articles and correlate them with other relevant findings in order to draw inferences related to the research question.

Policy implementation

The research by Gupta et al. (2012) elaborated on the fact that the implementation of the Janani Suraksha Yojana (JSY) was effective in increasing the rates of institutional deliveries by an estimated 42.6% among those that belong to poor socioeconomic status. The results demonstrated the fact that pregnancy in the initial stages creates great risk to mothers. As a result, an increase in institutional deliveries were found among the females belonging to the particular early age group resulting in substantial reduction in the maternal mortality ratio  and accomplishment of  Millennium Development Goal 5.

These findings were consistent with research conducted by Randive, San Sebastian, De Costa and Lindholm (2014) who stated that although there exists an inequality in the access to appropriate institutional delivery services, the JSY has the potential of reducing rates of such inequity. As per the research objective, the research by Gupta et al. (2012) has highlighted about the potential benefits of the JSY scheme. By increasing institutional delivery rate and hospital attendance among women, it can be interpreted that JSY has implemented strategies to reach those population which earlier preferred home delivery. Hence, the provision of cash incentive through the JSY scheme is the major contributor behind improved institutional delivery rate.

Similar type of cash incentive program was implemented in Nepal too and it revealed correlation between women’s knowledge about the program and the increased institutional delivery rate (Pandey, 2018). However, the findings related to increase in maternal mortality rate shows that the trend is common among lower-middle class and more number of cases became reported as more number of such families enrolled in hospital after being aware about the JSY scheme.

The article by Guin, Sahu, Khare and Kavishwar (2012) significant as it reveals some flaws in the JSY scheme.  The evidence revealed that JSY was able to put undue pressure on the rates of institutional deliveries, without creating provisions for earnest effort, with the aim of promoting the prominence of adequate antenatal care in decreasing maternal rates of morbidity and mortality. While there was an increase in the institutional delivery, pregnant women were brought in a dilapidated state to the hospitals, and there was an upsurge in the maternal mortality rates. This indicates lack of recruitment of trained and motivated personnel as some drawback of the planning process. The findings give the implication to remodel the JSY scheme to achieve the desired maternal health outcome.

However, Ng et al. (2014) presented results that did not confirm the association between reduction in maternal mortality and implementation of JSY. Their research instead illustrated that a significant improvement in the proportion of institutional deliveries in the state of Madhya Pradesh (23.9% in 2005 vs. 55.9% in 2010). Further increase were also observed in the proportion of institutional deliveries that were supported by JSY from 14% in the year 2005 to 80% in 2010. Nonetheless, declines in MMR during this time period ranged from 2% to 35%.

Another article by Goudar et al. (2013) elaborated on the trends related to institutional delivery, NMR (neonatal mortality), PMR (perinatal mortality) and risk factors in India. The results indicated that there was a significant increase in the rates of institutional deliveries from 2005-2009 of 92.6-96.1% in Belgaum, followed by 89.5-98.6% in Nagpur with a confidence level of (p<0.0001). Furthermore, the trends also provided evidence for an increase in the hospital rates from 63.4-71.0% (p=0.002), and 63.1-72.0% (p<0.0001), respectively. 

Owing to the fact that significant elevations in institutional deliveries were associated with decline in PMR from 41.3-34.6 (p=0.008), and in stillbirth from 22.5-16.3 in Belgaum and 29.3-21.1 in Nagpur (p=0.002), the researchers were able to establish effectiveness of institutional deliveries. It can be interpreted that the decline in PMR and stillbirth was due to an increase in neonatal resuscitation and caesarean section rates. Increase in hospital rates can be attributed to greater awareness and knowledge among the women on institutional deliveries and their benefits, in relation to infant and maternal health.

Khan, Hazra and Bhatnagar (2010) conducted a research that elaborated on the effects of Janani Suraksha Yojana. The findings presented in the article indicated that the fiscal incentives related to JSY and non-incentivized facilities, were able to bring about a successful contact between the client and the providers. This, in addition to ASHA counseling also increased the fraction of females who obtained institutional delivery and three ANC (ante natal) check-ups. The JSY practices which included the delivery of maternal and prenatal advice and counseling that in turn, generated the implementation of healthy behaviors, resulting in the improvement of both child and maternal health. Secondary data analysis from District Level Household Survey (DLHS-3) conducted in 2007-2008 suggested that more than half of the deliveries of India during the time frame occurred within the home (52%).

Financial burden

The out-of-pocket-expenditure (OOPE) for females being subjected to institutional deliveries were high, with substantial variation between the union territories and the states. The mean OOPE of normal delivery in private and public institution were an estimated Rs. 1,624 and Rs. 4,458, respectively. Corresponding rates for caesarean-section were approximately Rs. 5,935 and Rs. 14,276, respectively. For illiterate and poor women, the expenditures on caesarean sections were further than their capacity to pay, and subsequently resulted in suggestively more borrowings. Hence, the study was able to establish significant correlation between elevated wealth and literacy with an increased likelihood of institutional deliveries, and greater OOPE, without significant variations in JSY usage (Modugu, Kumar, Kumar & Millett, 2012).

Thus, it can be stated that the OOPE burden was high among less educated, low wealth index, and poor social group families. Data findings from a study conducted in Ghana suggested that there had been a marginalised upsurge in the access and utilisation of skilled delivery, antenatal and postnatal care services, after the implementation of appropriate policies. This illustrated the effectiveness of exemption of user fees for the maternal healthcare services, for the improvement of access to adequate care services (Ganle, Parker, Fitzpatrick & Otupiri, 2014).

Coffey (2014) conducted a qualitative study on the influences of conditional transfer of cash for birth in health facilities and provided evidence for the fact that that healthcare service providers primarily place an emphasis on apprehending the economic rents allied with the program, and deliver a tremendously poor quality of care. Further, the cash transfer program does not eventually deliver beneficiaries a great net fiscal transfer during the time of child birth. Hence, the value of the transmission to beneficiaries was found to be less due to the hospital birth associated costs.

These findings were supported by additional evidence presented by Carvalho, Thacker, Gupta and Salomon (2014) who suggested that financial support from JSY had an increase in the immunization rates ranging from fluctuating from 3.1 % polio vaccination to to 9.1% to completely vaccinated children. The findings were also able to provide proof of the impacts of JSY on an elevation in the rates of post-partum check-up and initial breastfeeding practices that were in use, during the time of childbirth. However, the research indicated that JSY failed to exert a major impact on care-seeking behaviours and exclusive breastfeeding practices.

Sidney, Diwan, El-Khatib and De Costa (2012) suggested that an estimated 76% of all deliveries (318/418) were found to occur within the JSY program, where approximately 81% mothers were present below the poverty line. The results further stated that 90% women had previous knowledge about the program. Most mothers reported getting cash incentive within two weeks of child delivery. The influence of ASHA on the decisions taken by the mothers regarding place of delivery was low. Increased susceptibility of infection during delivery at homes was found among women who were illiterate and did not have previous knowledge of the JSY package.

According to Powell-Jackson, Mazumdar and Mills (2015) also elaborated that that fiscal incentives to females were related with augmented uptake of maternity facilities. However, the authors failed to form a correlation between JSY and the decrease in early neonatal or neonatal mortality. The positive impacts on utilisation were found to be larger for less cultured and subordinate women, in homes where cash payment was more impactful. These results were supported by another study that indicated that maternal referral at the time of term delivery was related with greater odds of adverse birth outcomes (OR- 2.6, 95% CI: 1.0–6.6 p?=?0.04) (Chaturvedi, Randive, Diwan & De Costa, 2014). Hence, cash payments were allied with more utilization of maternity facilities among families that belonged to poor socioeconomic background.

Upon conducting an exploration of the child and maternal health under the scheme of the NRHM framework (National Rural Health Mission) it was found that the program makes the participation of PRI members through village health, sanitation, and nutrition groups mandatory, placing an emphasis on their participation in health based intervention at the grassroots level. However, inadequate monitoring by the committee authorities were regarded as a major barrier in monitoring the outcomes (Dwivedi, 2015).

While the ASHA programme did not direct towards HIV/AIDS, the CHW programmes (Community health workers) have been highlighted as an important means of targeting the shortage of health resource in under-developed countries, especially in association to HIV/AIDS (Scott & Shanker, 2010). This helped in establishing the fact that ASHA is a key component of the NRHM initiative and gains support by a noteworthy growth in government disbursement on public health (0.9% GDP to 2-3%). Thus, it can be stated that ASHA has been able to create an awareness on health and the associated social determinants, with the aim of mobilising the community towards better utilisation of the health services.

The paper by Vellakkal et al. (2017) mainly gave an insight into the role of different maternal and infant health programs in reducing inequity and quality issues in infant and maternal care. Paper 7 by Rao and Kaul  (2018) mainly gave idea regarding the impact of a scheme that particularly targeted infant health. The policy discussed in the paper was ICDS (Integrated Child Development Scheme). The ICDS scheme followed a life cycle approach to promote early child development. Services related to nutrition and community education was provided.

Since launch of the scheme in 1975, it was found that several restructuring initiavte to the scheme was implemented in the past 40 years. The study revealed challenges in achieving the objectives of the program because of the lack of health professionals to support the scheme. In addition, Vellakkal et al. (2017) highlighted about reduction in inequities through the NRHM program. The success was achieved because deprived population were targeted. Working in this area was significant and it is consistent with other research paper as conducted by Handa et al. (2016), who also revealed that poverty targeted schemes have the potential to improve maternal health.

This was supported by a separate investigation regarding the impact of Zambia’s Child Grant Program on maternal health utilization. Hence, on the whole deprived areas and population group were targeted to improve maternal and infant health in India. However, lack of preparation to meet the objectives of various schemes and poor implementation of the program affected ability to meet MDG (Millennium Development Goals) targets compared to other countries.   

Conclusion

By conducting systematic review of research literatures, the main aim of the paper was to evaluate the impact maternal and infant health related policies on improving maternal and infant health outcomes and indicators like MMR, access to care, quality of care and reduction in complication rate. By the process of screening of articles, a total of 8 papers were found to give answer to the research question. Furthermore, the review and critical analysis of the 8 papers gave rise to four different themes which gave clear idea regarding the impact of different policies on maternal health indicators.

The four themes included 1) impact of maternal policies on MMR and institutional delivery rate; 2) reducing financial barrier to access; 3) addressing inequities in maternal care; and 4) improving access to antenatal care. From the overall analysis of the eight papers, it can be concluded that the JSY scheme was a useful scheme that aimed to reduce MMR and pregnancy complication by avoiding. Offering cash incentives to deprived women was taken as a strategy to bring women to health care institutions for delivery. However, the review of observation studies like that of Gupta et al. (2012) revealed this could address behaviours like uptake of post-natal care, however it could not address the service gap that was present before the pregnancy.

Hence, instead of focusing on structural barriers to institutional delivery, the JSY stakeholders should have worked to focus on strategies to address cultural and geographical barriers in care. For example, the problem highlighted by Khan, Hazra  and Bhatnagar  (2010) was that quality antenatal care was not achieved because many women gained access to antenatal care in the last week of pregnancy. However, to identify risk and complication, there was a need to implement process to increase attendance in antenatal services from the beginning.

From the review of papers that particularly examine the impact of JSY scheme, it can be concluded that increasing uptake of institutional deliveries alone do not determine maternal health outcomes. The gaps and limitations in the implementation process revealed the need to assess the readiness of facilities in rural areas to provide quality care. Furthermore, training needs was also found as success of counseling and awareness will depend on communication and negotiation skills of health care workers. In addition, review of child development scheme like ICDS gave the implication that the program was not prepared to deal with diversity of the Indian population which affected the goal of achieving equitable provision of services.

Furthermore, many initiatives implemented under NRHM revealed improvement in outcome related to MMR. However, lot needs to be done still now to deal with cultural challenges like family preference for antenatal care, educational attainment of husband and attitude of women towards positive pregnancy outcomes. Hence, it is recommended that maternal health policy should go beyond institutional delivery and it should to address issues like malaria and tuberculosis in patient. It is also recommended to develop a comprehensive maternal health package that gives women idea about signs of good pregnancy outcome, types of services available and importance of good quality antenatal care. Language and cultural consideration must also be addressed while planning educational activities for at risk women population in India.

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