India has the highest rate of maternal deaths in the world. A major cause is that a significant proportion of women continue to deliver babies at home without the presence of a skilled attendant. This column says that distance to health facilities is a key barrier to seeking delivery care at a facility.
One-fifth of the 287,000 maternal deaths1 worldwide in 2010 occurred in India (WHO 2012). India is very likely to miss the Millennium Development Goal (MDG) for maternal mortality2. The current Maternal Mortality Ratio (MMR)3 in India is 212, whereas the country’s target in this respect, as per the MDGs, is 109 by 2015.
Institutional deliveries or facility-based births are often promoted for reducing maternal and neo-natal mortality4. Yet, many women in low and middle income countries, including India, continue to deliver babies at home without the presence of a skilled attendant5.
About a half of all births in India in 2007-2008 occurred at home without skilled attendance (District Level Household Survey (DLHS-3)). Institutional deliveries in India range from about 35% in Chattisgarh to 76% in Madhya Pradesh. Of the 284 districts in nine high-focus states6which accounts for 62% of maternal deaths in the country, institutional delivery is less than 60% in 170 districts (Annual Health Survey (AHS) 2011).
Besides reducing maternal and neo-natal mortality, institutional deliveries are also believed to improve health-seeking behaviour and practices in the period following childbirth. Children born at a health facility are more likely to be vaccinated and breastfed (Odiit and Amuge 2003). Properly vaccinated and adequately breastfed children are less likely to be malnourished and have better health. Additionally, poor childhood health can have an adverse effect on educational attainment as well as on adult work productivity, and can hence affect adult earnings (Bleakley 2010). Therefore, institutional delivery can also be thought as an investment in human capital and can play an important contributory role in the development process of the economy.
Barriers to visiting a health facility
Women face various barriers to visiting a health facility to seek delivery care. These include cost of care, access to clinics, cultural factors, quality of care, and a lack of health awareness.
To relax the financial barrier, the Government of India launched Janani Suraksha Yojana (JSY) in 2005. JSY is a conditional cash transfer programme that provides a cash incentive to women who give birth at public health facilities. Rural women receive Rs. 1400 ($28 approx.) and urban women receive Rs. 1000 ($20 approx.,) upon delivery at a public health facility. All services provided at the public health facility are free of charge.
The success of JSY has been mixed so far - the percentage of mother availing financial assistance ranges from less than 15% in Jharkhand to about 60% in Odisha (AHS 2011).
Too far to travel
Physical access is an important barrier as longer distances entail higher transportation and opportunity costs. Distance to health services exerts a dual influence on use - it is a disincentive to seeking care in the first place, and also an actual obstacle to reaching care after a decision has been made to seek it (Thaddeus 1994). The adverse effect of distance is stronger when combined with lack of transport, poor roads, and poor quality of care.
In a recent study, we attempt to unravel the causal effect of distance to health facilities on institutional delivery in rural India (Kumar et al 2013). It is very important to understand the effect of the access barrier as it greatly depends on contextual factors. For instance, distance may become irrelevant in a setting with high-quality health facilities and transport infrastructures. Some studies have shown that households are keen to travel longer distances for high-quality care (Collier et al 2002).
Analysing the distance barrier
Using DLHS-3, a nationally representative household dataset, we find that distance to health facility is a significant barrier and adversely affects the number of institutional deliveries in India. For a 1 km increase in the distance to health facility, there is a reduction of about 4% in the chances of opting for an institutional delivery. At the average distance of 9 km from a Primary Health Centre (PHC), there is a 64% chance of opting for institutional delivery.
Additionally, the study finds that women who live 5-9 km away from the nearest health facility are 13% less likely to opt for institutional delivery as compared to women that live 0-5 km away from the nearest health facility. When the distance increases to more than 9 km, the chances of institutional delivery are reduced by 30% (as compared to a distance of up to 5 km). Based on a thought experiment conducted as part of the study, we find that if additional facilities are built such that the maximum distance of a health facility is restricted to 5 km, institutional deliveries will rise significantly.
We also find that women living in households that own cars or other motorised vehicles are more likely to deliver in health facilities. Poor road connectivity also deters women from visiting a health facility for delivery care.
What should be done?
Our findings indicate that in countries such as India, where distances to health facilities are quite large in rural areas, geographical access to health care is a significant barrier to institutional delivery. An increase in the density of health facilities and providers in rural areas is likely to greatly help improve maternal and neo-natal care. A comprehensive cost-effective analysis should be undertaken to demonstrate that the benefits would outweigh the cost of building new facilities.
In addition, it is important to improve road and transport infrastructure to reduce inequity in access to health facilities, and thereby, increase institutional deliveries.
- Maternal death is the death of a woman during pregnancy or within 42 days of termination of pregnancy
- The target is to reduce the 1990 level of the Maternal Mortality Ratio by three-quarters by 2015
- Maternal mortality ratio refers to the ratio of the number of maternal deaths per 100,000 live births
- Neo-natal mortality refers to the death of a live-born baby within the first 28 days of life
- A Skilled Birth Attendant is a midwife, physician, obstetrician, nurse, or other health care professional who provides basic and emergency health care services to women and their newborns during pregnancy, childbirth and the period right after childbirth
- Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, Uttar Pradesh and Assam
- Bleakley H. 2010. Health, human capital, and development, Annual Reviews of Economics, 2:283-310.
- Collier Paul, Dercon Stefan, and John Mckinnon. 2002. Density versus quality in health care provision: using household data to make budgetary choices in Ethiopia. World Bank Econ Rev 16(3): 425-448.
- Kumar S, Dansereau E, Murray CJLM. 2013. Does distance matter for institutional delivery in rural India? An instrumental variable approach, MPRA Paper No. 45762.
- Odiit A, Amuge B. 2003. Comparison of vaccination status of children born in health units and those born at home, East African Medical Journal, 80(1).
- Thaddeus S, Maine D. 1994. Too far to walk: maternal mortality in context. Soc Sci Med, 38(8):1091-1110.