The Influence of Cash Conditional Programs on Neonatal
Outcomes: Estimating the Impact of the JSY on Birth Asphyxia
Mortality in India
Master’s Thesis
Katelin Hairgrove Moran
November 2013
1
Acknowledgements
My deepest thanks to all have supported and mentored me in developing and writing this
master’s thesis. My thanks to Bonnie Jones for her mentorship in modeling, support in the
conceptualization of this paper, feedback in the initial drafts, and most of all, her unwavering
support that enabled me to complete this analysis. My thanks to Jennifer Griffin for her
mentorship in modeling, guidance in understanding birth asphyxia, feedback on several drafts,
and wise guidance during conversations about the limitations but importance of modeling. My
thanks to Trude Bennett for her academic guidance in the Maternal and Child Health Department
and feedback for several drafts of this paper. Additional thanks to the MANDATE clinical team Beth McClure, Doris Rouse, Yanica Faustin, and Robert Goldenberg– for their investment,
support, and guidance in the field of maternal and neonatal health and modeling.
I would like to thank my sweet husband, Jeff, who is my biggest cheerleader. He has gladly
listened to (and attempted to understand) hours of my ramblings about global maternal and
neonatal health issues. He picked up all my slack of cooking, cleaning, doing laundry, and yard
work, all with a smile on his face. He is truly my best friend and loves me well in both word and
deed.
Lastly, I would like to thank my Hairgrove and Moran family, who have always believed in me
and supported my passions. I wouldn’t be where I am today without you.
2
Introduction
Birth asphyxia (BA), also referred to as intrapartum-related events, is one of the leading causes
of neonatal deaths worldwide. Recent estimates suggest that up to 10 million neonates develop
BA each year [1]. Globally, approximately one million of these neonates die from BA,
accounting for 23% of all neonatal deaths [2]. Among high-resource countries (HRCs), increases
in hospital deliveries and specialized care have resulted in marked decreases in BA mortality
rates [3], while low-resource countries (LRCs) continue to have high BA mortality rates [1-4].
BA requires access and intervention by skilled providers (SPs) trained in resuscitation with the
appropriate diagnostic and interventional technologies to treat the condition in a swift and
targeted manner. Studies estimate that if left untreated, BA in neonates results in a 4-15% case
fatality rate among moderately asphyxiated neonates while the case fatality rate of neonates with
severe BA approaches 40% [5-7]. There is no known prevention to avert the onset of BA apart
from improved obstetric care for the mother [4]. However, the evidence is clear that access to
and treatment by SPs is critical in reducing BA mortality [4].
Among LRCs, India is one of the highest contributors to the global burden of BA mortality, with
an estimated 170,000-190,000 neonates dying from BA annually [8-11]. Increasing political and
social will in India during the last decade to address poor maternal and neonatal outcomes has
led to an increase in hospital deliveries. A Family Health Survey in India in 1999 reported over
65% of deliveries occurred at home, while the remaining 35% of deliveries occurred in health
facilities (hospital and clinic)[12]. However, surveys from 2009-2011 reported that up to 75% of
women deliver in health facilities [13-15]. The increase in hospital deliveries has been attributed,
in part, to the introduction of Janani Suraksha Yojana (JSY), a conditional cash transfer program
[13, 15, 16].
3
The JSY conditional cash transfer program was created in April 2005 under the umbrella of the
National Rural Health Mission in an effort improve maternal and neonatal health in India,
especially among its population below the poverty line [15]. Janani Suraksha Yojana literally
translates to Maternal Protection Scheme. The primary objective of the JSY is to reduce maternal
and infant mortality through encouraging institutional care and deliveries [15]. This objective is
achieved through providing financial incentives for women to attend antenatal care and to deliver
in public institutions (some women are eligible for benefits in private institutions). The cash
incentive is 600-1,000 rupees (or approx. $20) for women from urban settings and 700-1,400
rupees (approx. $28) for rural settings [15, 17, 18]. For perspective, the India GNP was
approximately $1000 in 2007.
JSY is being implemented through community health works called accredited social health
activists (ASHAs) whose role is to identify pregnant women and to encourage them to attend
ANC, institutional delivery, and postnatal care (PNC). Of note, ANC and PNC are free in public
institutions. ASHAs are intended to serve as a link between the public health system and local
community. ASHAs receive 200 rupees ($4) in urban area and about 600 rupees ($12) per
delivery in rural areas. On average, ASHAs spend approximately 40-60 hours with each case
[17].
The program has rolled out incrementally, with most districts having JSY coverage by 2008. It
was estimated that between 2009-2010 the JSY provided financial incentives to 36% of the 26
million women who gave birth [16]. Since this point, it is estimated that pregnant women have
been increasing their uptake in the JSY program [15].
4
To our knowledge, there have been no studies that have estimated the potential number of
neonatal lives saved if all women delivered in a hospital setting in India. Thus, the objective this
analysis is to estimate the number of neonatal lives saved from birth asphyxia mortality through
the scale up of hospital deliveries in India, as facilitated through programs like the JSY. In
addition, this analysis estimates the impact of additional training in the recognition and diagnosis
of BA and improved coverage of technologies to treat BA. This analysis can be used by health
providers and policy makers to determine what interventions to invest in that would maximize
the numbers of neonatal lives saved.
Methods
To assess the impact of increases in hospital level deliveries in India on mortality rates of BA,
we developed a BA model utilizing the Maternal and Neonatal Directed Assessment of
Technology (MANDATE) model. MANDATE is a mathematical modeling tool that has been
developed to quantify the impact of technologies on maternal and neonatal conditions in low
resources settings. MANDATE evaluates maternal, fetal, and neonatal mortality associated with
maternal and neonatal conditions. The model accounts for different delivery care settings of the
home, clinic, and hospital and evaluates the impacts of various technologies (diagnostic,
preventative, and treatment) implemented in these settings. Each technology in the model is
assessed by three criteria: penetration, utilization, and efficacy. Penetration is defined as the
availability of an intervention within a setting. Utilization is defined as the appropriate clinical
use of the technology for the condition. The coverage rate of a technology is estimated by the
multiplication of penetration and utilization rates. Efficacy rates, which is defined as the
expected effect with ideal use, remains constant across settings. A set of scenarios are run for
each condition to evaluate the impact of the coverage and efficacy of technologies on maternal
5
and/or neonatal mortality rates. These scenarios generally include a no treatment scenario that
assesses the mortality rates if no interventions exist, a baseline scenario that assesses current
levels of interventions and their impact on mortality, and then additional scenarios to examine
the impacts of altered coverage rates on mortality outcomes. MANDATE also has the ability to
assess the impact of transfers between settings, usually secondary to an improvement in
diagnostics.
The data that populated the MANDATE BA model are derived from a systematic literature
review of BA in India. Hundreds of articles and reports were collected and assessed from Google
Scholar, the Cochrane Library, WHO database, Demographic and Health Surveys, United
Nations estimated mortality rates, India Census data, and variety of other sources that contained
relevant data. A modified algorithm using the GRADE system was applied, in which
MANDATE estimates were primarily selected from the highest quality sources, with support
from other sources when limited data were available [19].
The MANDATE model distinguishes delivery settings between home, clinic, and hospital.
However, India’s health system is complex with sub-centers, primary health centers, community
health centers, district hospitals, and tertiary hospitals. For the purpose of this analysis, home
delivery is defined as any residential delivery location, this being most often the maternal home.
Clinic includes health centers that provide basic emergency obstetric services. Hospital is
defined as a health center that offers comprehensive obstetric services. In general, we categorize
sub-centers and primary health centers under the category of clinic while community health
centers, district hospitals, and tertiary hospitals are grouped under the category of hospital. For
this analysis, we did not differentiate between private and public hospitals.
6
Table 1 defines the key variables that were held constant over the analysis of neonatal mortality
from birth asphyxia in India. Based on United Nations data, we estimate that there were
approximately 28.4 million live births in 2002, 27.3 million live births in 2012, and a projected
25.1 million births in 2022 [20]. For term neonates, the estimated weighted incidence rate is 5%
across all settings, taking into account a lower incidence of BA in clinics and hospitals due to
improved obstetric care [21-23]. The case fatality rate of untreated BA, or asphyxia related
mortality within the first 24 hours of birth, is estimated at 12% [7, 24-26]. We estimate that
approximately 15% of neonates with BA that survive the first 24 hours will go on to have
asphyxia related injury, such as hypoxic ischemic encephalopathy or multi-organ dysfunction
[27]. We estimate that these BA injury cases have an untreated case fatality rate of 12% [28].
Finally, in 2002 before JSY was implemented in India, an estimated 65% of all deliveries
occurred in the home, 20% in the health clinic, and 15% in the hospital. In 2012 approximately
35% of all deliveries in India occurred in the home, 25% in the health clinic, and 40% in the
hospital [12, 14].
This study uses MANDATE to estimate the impact of hospital level delivery and quality of care
on BA mortality trends in India between 2002 and 2022. This analysis is restricted to BA among
term neonates in India. The outcomes of interest are mortality from BA and BA related injury.
For this analysis, MANDATE ran a series of five scenarios in ten-year increments, ranging from
2002 to 2022. The five scenarios provide estimates for BA mortality if that were no
interventions/treatment (2002), baseline interventions/treatment before JSY was implemented
(2002), baseline interventions/treatment several years after the implementation of JSY (2012),
projected outcomes based on improved delivery location (2022), and project outcomes based on
improved delivery location and care (2022). The penetration (i.e. availability of technology),
7
utilization (i.e. appropriate use of a technology), and efficacy (i.e. best intervention effect
achieved with ideal use) rates used for the baseline scenarios are summarized in Table 2. Of note,
the penetration and utilization rates are likely different between the 20 year span that is
compared; however for the sake of simplicity, these rates remained constant. Manipulating only
the variables of delivery location and transfer rate allows for a clearer analysis of the impact of
delivery location on birth outcomes.
Findings
Comparisons of the five scenario outcomes are summarized in Table 3. Each scenario is
examined through following categories: the total incidence of BA across all delivery settings, the
total incidence of BA within the hospital, and total number of neonatal deaths from BA and BA
related injury. Finally, the bottom row highlights the number of lives saved as compared to
scenario 2, the baseline 2002 scenario estimating birth asphyxia mortality prior to the
introduction of the JSY.
Scenario 1 presents MANDATE 2002 neonatal mortality rates from BA if no birth asphyxia
interventions were available in India, both for the mother and neonate. In this scenario, there are
no diagnostics, transfers, or treatment technologies used, thus estimating the worst outcomes for
neonates with BA. Since improved obstetric care is not factored in, the incidence of BA is
increased to 7% across all settings [26, 29]. This scenario estimates that approximately 267,828
neonates would die from BA.
Scenario 2 presents MANDATE in year 2002 neonatal mortality from BA if baseline birth
asphyxia interventions are available across settings. These interventions include manual
stimulation, neonatal resuscitation, and advanced resuscitation/NICU care. Assumptions
8
regarding baseline levels of birth asphyxia interventions are summarized in Table 2. Of note, this
scenario distributes deliveries across settings according to the DHS 1998 estimates of 65% home,
20% clinic, and 15% hospital. Scenario 2 approximates that 240,057 neonates would die from
BA in India annually prior to the implementation of the JSY.
Scenario 3 presents MANDATE 2012 neonatal mortality with no change in baseline birth
asphyxia interventions. In Scenario 3, I estimate that after seven years after the implementation
of the JSY, approximately 35% of neonates are born at home, 25% in the clinic, and 40% in the
hospitals (REF). The primary difference between Scenario 2 and 3 is the change in the delivery
distribution across settings. This scenario estimates that approximately 184,701 neonates died
from BA in 2012. The MANDATE model estimates of neonatal mortality from BA are validated
from research studies estimating birth asphyxia mortality in India[10, 11]. Compared to Scenario
2, approximately 55,356 neonatal lives would be saved. As shown in Table 3, increased hospital
deliveries are estimated to have a marked impact on BA mortality.
Scenario 4 presents MANDATE estimates for 2022 if optimal delivery setting is achieved,
similar to the distribution seen in HRCs. Deliveries are distributed across settings at 1% at home,
1% in clinics, and 98% in hospitals. This scenario estimates that 95,333 neonates would die from
BA. Compared to Scenario 2, approximately 144,724 neonatal lives would be saved.
Scenario 5 presents MANDATE estimates for year 2022 if optimal delivery setting and quality
of care were close to the levels in HRCs. Delivery distributions are the same as Scenario 4 but
birth asphyxia intervention coverage rates are increased to almost universal levels of availability
and utilization at 99%. This scenario estimates that 77,941 neonates would die from BA.
Compared to Scenario 2, approximately 162,116 neonatal lives would be saved.
9
Interpretation
To my knowledge, this is the first quantified analysis estimating the number of neonatal lives
saved from BA since the increase in the proportion of hospital deliveries in India. Further, this
analysis provides the first estimate of the potential number of lives saved from BA if most
women delivered in the hospital, which is the primary goal of the JSY program.
Scenarios 1 and 2 suggest that increases in the coverage of technologies have little impact if
women are not delivering in settings with SPs. BA is a condition with a short time frame for
intervention with, at most, a 5-minute window for intervention before the neonate suffers injury
or fatality [21]. As a result, increases in transfers between settings are expected to have little
impact on the outcomes of neonates with BA. The majority of BA cases will be resolved if basic
neonatal resuscitation techniques are implemented by trained SPs, who primarily occupy
hospitals [1].
Scenarios 3 and 4 suggests that scaling up hospital deliveries has the largest impact on neonatal
mortality from BA. Scenario 3 estimates show that scaling up hospital deliveries since the JSY
was implemented saves approximately 55,000 lives annually, as compared to the 2002 pre-JSY
baseline. Scenario 4 estimates show that near universal hospital deliveries will save almost
150,000 lives annually as compared to the 2002 pre-JSY baseline. Further, Scenario 5 illustrates
that improved quality of care through near universal coverage of BA intervention technologies
will save almost 165,000 lives annually.
As illustrated in Scenario 4, the MANDATE model estimates if the JSY accomplishes their goal
of having all women deliver in hospitals, almost 100,000 neonatal lives would be saved annually
from BA as compared to the current mortality. This estimate takes into consideration current
10
realities of access and appropriate use of technologies in hospitals, as shown in table 2.
Intervention technologies are not always available. Further, technologies that are available are
not utilized in a clinically appropriate manner. These two realities need to be addressed in order
to accomplish optimal results estimated through Scenario 5. Ideal results from cash conditional
programs like the JSY are optimized when the health infrastructure and capability are improved
through additional SP training and coverage of technologies.
Conclusion
Between 2002 and 2012, India experienced an approximate 25% decrease in annual neonatal
mortality rates [30]. There is no indication in the literature that birth asphyxia decreased at a
different rate than all-cause neonatal mortality, leading us to assume that birth asphyxia neonatal
mortality has decreased at similar rates. The MANDATE model estimates a similar decrease
with approximately 29% decrease between 2002 and 2012. This difference in neonatal mortality
rate decreases may be attributed to a small margin of error or may relate to a slight decrease in
quality of care due to higher caseloads in hospitals without the staffing capacity to accommodate
them. Overall, this analysis supports that improved delivery location and care will reduce BA
mortality. Even with controversy surrounding the decreased quality of care in Indian hospitals
since the JSY was implemented [16, 31], this model suggests that neonates with BA will still
have improved outcomes with lower coverage rates of technologies, due in part to the basic
neonatal resuscitation delivered by SPs in hospitals.
There are a number of potential limitations to this study. First, despite a thorough examination of
the literature base and great effort to develop the best estimates for the model, the data available
is often limited. Other parameter estimates can be justified from those used in the MANDATE
11
model, however our team selected the best possible estimates with the available data. Secondly,
creating a computerized model assessing the impact of different delivery settings may not
capture human dimension on delivery outcomes. Perceptions, experiences, beliefs, and cultures
that impact delivery care and medical decisions are difficult to quantify, allowing room for error
in this model. Lastly, our analysis assumes that quality of care within facilities remains constant
as caseloads increase. In all likelihood that as caseloads increases, facilities may be understaffed
and quality of care decreases. Despite these limitations, the numbers produced through the
MANDATE model approximate global estimates [8, 10, 11]. The sophisticated nature of the
MANDATE model, created through pooling hundreds of clinical trials, surveys, and data sets,
provides a powerful and unique tool to assess and quantify the impact of technology
interventions on maternal and neonatal mortality.
The JSY has served as an impetus to facilitate a shift in delivery culture within India and, with
this culture shift, tens of thousands of neonates with BA will continue to live [15]. We speculate
that LRCs with high neonatal mortality rates, similar to India, would benefit from conditional
cash transfer programs such as the JSY in efforts to curb poor neonatal outcomes. It bears
mentioning that programs like the JSY experience growing pains, such as understaffed hospitals,
overcrowded conditions, and reduced quality of interventions [32]. In summary, this analysis
provides the first quantified estimate of the impact of the hospital births on neonatal mortality
from BA in India, facilitated through programs such as the JSY. This study suggests that
increasing hospital deliveries, as opposed to focusing on increasing the coverage of technologies,
has the greatest impact on neonatal BA mortality.
12
Table 1. Estimates of live births, delivery setting distributions, and birth asphyxia incidence and case
fatality rate in India, from 2002-2022.
India
N or %
Live Births 2002
28,381,391
Live Births 2012
27,321,769
Live Births 2022
25,130,525
Site of Delivery Care (2002)
Hospital
15%
Clinic
20%
Home
65%
Site of Delivery Care (2012)
Hospital
40%
Clinic
25%
Home
35%
Weighted Incidence*
5%
Case Fatality Rate for BA and
BA Injury *
12%
*The incidence and case fatality rates assume no neonatal preventative or treatment interventions, but
incorporate differences in baseline levels of emergency obstetric care in the various settings.
13
Table 2. Baseline penetration, utilization, and efficacy estimates for birth asphyxia interventions in home,
clinic, and hospital settings in India.
Setting
Home
Clinic
Hospital
Penetration
50%
80%
98%
Utilization
75%
95%
98%
Efficacy to Diagnose need for resuscitation
85%
85%
85%
Penetration
50%
0%
0%
Utilization
50%
0%
0%
Efficacy to Diagnose need for PRC
58%
58%
58%
Penetration
0%
80%
90%
Utilization
0%
50%
75%
Efficacy to Diagnose need for PRC
87%
87%
87%
Penetration
50%
99%
99%
Utilization
75%
90%
95%
Efficacy to Reduce BA Mortality
15%
15%
15%
Penetration
10%
80%
99%
Utilization
20%
50%
75%
Efficacy to Reduce BA Mortality
40%
40%
40%
Diagnostics
Recognition of need for resuscitation
Mother VO of Need for Post-Resuscitation Care (PRC)
Clinician Diagnosis for PRC
Treatment
Manual Stimulation
Bag and Mask
14
Oxygen
Penetration
0%
75%
99%
Utilization
0%
50%
75%
Efficacy to Reduce BA Mortality
25%
25%
25%
Penetration
0%
2%
20%
Utilization
0%
50%
70%
Efficacy to Reduce BA Mortality
50%
50%
50%
Penetration
0%
0%
15%
Utilization
0%
0%
90%
Efficacy to Reduce BA Mortality
25%
25%
25%
CPAP
Ventilator and Advanced NICU Care
Transfers with VO/Diagnosis of need for PRC
Home to Clinic
20%
Home to Hospital
30%
Clinic to Hospital
50%
15
Table 3. Estimated total and hospital birth asphyxia cases, birth asphyxia neonatal mortality and lives
saved for modeled scenarios.
No treatment 2002
Scenario (1)
Baseline 2002
scenario (preJSY) (2)*
Baseline 2012
scenario (3)*
Improved
delivery location
2022 scenario
(4)*
Improved
delivery care
and location
2022 scenario
(5)
Total Cases of
neonates who
develop Birth
Asphyxia
1,941,210
1,673,600
1,376,872
876,040
876,040
Cases of Birth
Asphyxia in the
Hospital
194,121
128,952
343,871
842,485
842,485
Total Neonatal
Deaths from Birth
Asphyxia and
Birth Asphyxia
Related Injury
297,650
240,057
184,701
95,333
77,941
Total Lives Saved
as compared to
Baseline 2002
scenario (2)
NA
NA
55,356
144,724
162,116
Scenario
*Baseline treatment includes estimates for current levels of birth asphyxia diagnostics, treatments, and
transfers, as shown in Table 2.
16
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