Population Council Research that makes a difference

2011 International Conference on Family Planning
29 November–2 December 2011

Abstract

"How conditional cash transfers to promote institutional delivery can also influence postpartum contraception: Evidence from Rajasthan, India"
A.J. Francis Zavier, K.G. Santhya, Shireen Jejeebhoy, and Rajib Acharya

Background
There is growing evidence from numerous countries that conditional cash transfers (CCTs) have leveraged sizeable gains in access to health services, especially in countries with low levels of access. The Janani Suraksha Yojana (JSY) in India, the largest CCT programme in the world in terms of the number of beneficiaries, is intended to encourage institutional delivery, provide access to care during pregnancy and in the postpartum period. The Accredited Social Health Activists (ASHAs), who serve as the interface between women and the public health system, play an important role in enabling women to avail of the JSY. ASHAs’ responsibilities include, among others, making a postpartum visit to women within 7 days of delivery to track the mother’s health after delivery, facilitating access to care, as well as promoting family planning services. Evaluations of the JSY thus far have assessed the effects of the JSY on the uptake of maternal health services and on improving newborn health. Evidence, however, remains limited about whether or not postpartum contraceptive use has improved with the introduction of JSY.

Objectives
The paper examines the association between the receipt of JSY benefits and postpartum contraceptive use. Specifically, it examines differences, if any, between JSY beneficiaries and non-beneficiaries in the adoption of contraception within three and six months of delivery, respectively, as well as in method choice made by contraceptive users.

Methodology
A cross-sectional study was conducted among women aged below 35 years who had delivered in the one year preceding the interview in rural and urban areas of Alwar and Jodhpur districts of Rajasthan, India, during September 2009–February 2010. A total of 4,770 women were successfully interviewed during the survey. Three indicators of postpartum contraceptive use were used: adoption of contraception within 3 months of delivery among those who had delivered 4–12 months preceding the interview; adoption of contraception within 6 months of delivery among those who had delivered 7–12 months preceding the interview; and type of method (non-terminal versus terminal) adopted among those who had adopted contraception following delivery. The receipt of JSY benefits measured whether or not the respondent had received the cash assistance. To assess the association between the receipt of JSY benefits and postpartum contraception, we used data from a matched sample of JSY beneficiaries and non-beneficiaries who had delivered in the one year preceding the interview, selected using the technique of propensity score matching. This analysis was restricted to the matched sample since the socio-demographic characteristics of those who had availed of cash assistance differed significantly from those who had not. A total of 3,434 beneficiaries and non-beneficiaries thus selected constituted the sub-sample used for the analyses. Mean values of outcome variables obtained for beneficiary and non-beneficiary groups were first compared to assess the extent to which the adoption of postpartum contraception differed between the two groups and t-tests were used to test the significance observed in the bi-variate comparisons. Additionally, we used regression analyses to account for potentially confounding effects that such covariates as age, education, religion, caste, parity, household economic status, rural-urban residence, postpartum contraceptive counselling status, husband’s involvement in pregnancy-related care, quality of pregnancy-related care and study district might have had on the outcome measures.

Results
Adoption of postpartum contraception was limited among study participants. Even so, women who had availed of JSY benefits were more likely than those who had not to have adopted postpartum contraception (20% versus 15%). They were also more likely to report early adoption of postpartum contraception. Among women who had delivered 4–12 months preceding the interview, 14% and 9% of beneficiaries and non-beneficiaries, respectively, had begun using a method within three months of delivery. Among women who had delivered 7–12 months preceding the interview, 22% and 15% of beneficiaries and non-beneficiaries, respectively, had begun using a method within six months of delivery. Differences were narrow with respect to method choice. Among those who had adopted contraception, the beneficiaries were as likely as the non-beneficiaries to have used non-terminal methods (65% versus 62%). Bi-variate associations observed with respect to the timing of postpartum contraceptive adoption were reiterated in the multivariate analyses. Even after controlling for potentially confounding factors, beneficiaries were 1.3 and 1.4 times as likely as non-beneficiaries to have adopted contraception within three and six months of delivery, respectively.

Knowledge contribution
Findings advance what is known about the spin-offs of CCTs intended to promote institutional delivery in general and of India’s JSY in particular. Programmatically, findings make a case for special efforts to use the increased opportunity to interact with the health system as a result of CCTs for promoting maternal and newborn health practices, including postpartum contraception.

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