By Maya Palit
On social media on 1 January, I came across many quips about Prime Minister Narendra Modi’s New Year’s Eve speech. “Judging from the speech, the happiest person in the country should be a 65-year-old pregnant farmer,” went one. These were, of course, prompted by Modi’s promise to introduce a scheme that would transfer Rs 6,000 to the bank accounts of pregnant women. He portrayed it as a new scheme that would help to curb maternal mortality, but as the national media has pointed out, there is nothing new about the concept of benefits for pregnant women. They were mentioned in a clause in the National Food Security Act passed in 2013. And were part of various other schemes like the Janani Suraksha Yojana (JSY) launched in 2005 and the Indira Gandhi Matritva Sahyog Yojana (IGMSY), a centrally sponsored ‘pilot’ scheme introduced in 53 districts around the country in 2010 which had 61,972 beneficiaries between 2010-2011 and 2013-14. And in the meantime, like Tamil Nadu have already adopted their own version of maternity benefits, using their own resources, like the Dr. Muthulakshmi Reddy Maternity Benefit Scheme which provides Rs 12,000 for pregnant women below the poverty line.
Although Modi did not spell out in his speech precisely the conditions that would make women eligible, if his scheme resembles previous maternal benefit schemes, it could be a massively exclusionary measure. The IGMSY, for instance, mandated that Rs 4,000 would be transferred to women in installments if they:
1. Registered their pregnancies at an Anganwadi centre (AWC) or health centre.
2. Gave birth in government institutions, carried out exclusive breastfeeding for six months.
3. Received at least one antenatal check-up and counseling session at an AWC.
4. Ensured that their children were vaccinated for polio, BCG and DPT.
And these are only four of the many conditions. Although you could well argue that these requirements are intended to motivate pregnant women towards ‘healthier’ behaviour, they end up effectively excluding approximately 60 percent of the country’s women who don’t deliver in hospitals, and a vast majority of those without bank accounts of their own, or control over financial matters in the family. How many daily wage labourers, for instance, have the privilege of breastfeeding their child for an entire six months?
And perhaps most importantly, as Rakhal Gaitonde, a public health researcher with Medico Friend Circle, explained, conditional cash transfers shift the discourse and priorities of the public health system (PHS): “I recall the case of a young woman in Tamil Nadu who had diarrhoea after pregnancy and requested the nurse to treat her, but the nurse was single-mindedly focused on filling out the forms related to the scheme. The PHS becomes more focused on eligibility criteria and neglects its larger work. When the Rural Women’s Social Education Centre asked women about their priorities when giving birth, they came up with suggestions including clean surroundings and helpful doctors. Incentivising people who need the money, rather than instituting changes at the PHS level, is a bizarre insult to the innate intelligence of people who often avoid healthcare facilities because of the appalling conditions there.”
The obstacles to women accessing healthcare in the first place are innumerable. “In Odisha, we asked for maternity death review reports and found that there is an entire spectrum of factors, rather than a single barrier that make access to institutionalised healthcare difficult for women,” said Sarita Barpanda, who works with the reproductive rights initiative at the Human Rights Law Network (HRLN). “In the North East, many maternal deaths occur because of the lack of transportation and difficult roads, and in Odisha women tend to lose their lives because sufficient health services are not available. But the bottom line is that health services are disrespectful and often abusive,” she explained.
According to Jashodhara Dasgupta, Senior Adviser at SAHAYOG and previous convenor of the civil society programme National Alliance for Maternal Health and Human Rights (NAMHHR), a recent attempt to document close to 150 maternal deaths revealed that one big factor was the lack of available transportation. In Adivasi areas in Odisha and Jharkhand, which do not always have cellphone connectivity and reliable transport, it isn’t easy for a woman to make it to a hospital in time. And if a woman has the baby on the way, it renders her disqualified from the scheme. Furthermore, the IGMSY conditions that women has to be over 19 years of age (given that the national mean for the age of marriage was 19.3 years in 2011, this is an exclusionary condition in itself) and have no more than two children tended to disqualify the poorest families, which include Dalit and Adivasi women, who really need the scheme.
But Dasgupta singled out one major form of exclusion preventing women from accessing healthcare. “In Malda and Murshidabad, Muslim-dominated regions in West Bengal, we found that there were doctors present in peripheral districts, but women did not opt for hospital deliveries because of immense hostility, and only went when there were serious complications. They were usually poor and had more than the approved number of pregnancies, and were treated badly – in UP, for instance, Dalit women were left to lie bleeding in a verandah – so they may prefer being in a more empathetic environment.”
Fact finding reports by HRLN in Balasore, (Odisha) North Cachar (Assam), and Bilaspur (Chhattisgarh) cite doctors’ negligence, obstetric violence, anaemic conditions, and delays in ambulance arrivals as the major reasons for maternal deaths. An HRLN study in Seelampur, a sub-district of Delhi, corroborates Barpanda and Dasgupta’s findings, showing that women had not received maternal benefits because they avoided government hospitals being afraid of physical and verbal abuse from the staff. But others, who had gone through the processes that made them eligible for maternal benefits, were still not made aware of or given any benefits, and often only informed about one kind of contraception.
Perhaps, as Ravi Kumar, a rural surgeon working in Tamil Nadu, emphasised, improving the quality of health services in government hospitals, and making home deliveries safer, have to be focussed on before offering incentives for people to deliver in government hospitals. Given the array of factors preventing women from accessing healthcare, Modi’s declaration that a conditional cash transfer scheme, which disqualifies a vast section of women, will bring down maternal mortality appears counter-intuitive and shortsighted (particularly given that providing cash benefits to pregnant women in all states would require Rs 16,000 crores, whereas the current budget stands at Rs 400 crore).
As Dr Prasanta Tripathy, a board member of Ekjut, an NGO working on maternal health in districts across India, said sadly, in the meantime it is jugaad rather than conditional schemes that saves maternal lives.
Co-published with Firstpost.