One-fifth of the 2,87,000 maternal deaths worldwide in 2010 occurred in India (WHO 2012). India is very likely to miss the Millennium Development Goal (MDG) for maternal mortality. The current Maternal Mortality Ratio (MMR) 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 mortality. Yet, many women in low- and middle-income countries, including India, continue to deliver babies at home without the presence of a skilled attendant.

About 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 Chhattisgarh to 76% in Madhya Pradesh. Of the 284 districts in nine high-focus states which account 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 the 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 1,400 ($28 approx.) and urban women receive 1,000 ($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 mothers availing financial assistance ranges from less than 15% in Jharkhand to about 60% in Orissa (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—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 data set, 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.

Santosh Kumar, PhD, is a lecturer of Global Health Economics at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

Emily Dansereau is a post bachelor fellow at the Institute for Health Metrics and Evaluation, and an MPH candidate at the University of Washington.

Christopher J.L. Murray, MD, DPhil, is a Professor of Global Health at the University of Washington and Institute Director of the Institute for Health Metrics and Evaluation (IHME).

This column has been reprinted with permission from Ideas for India