Predictors of out-of-pocket expenditure on institutional delivery in states of India with the highest and lowest proportion of institutional delivery

Abstract

Background: Institutional delivery is an integral constituent in curbing maternal mortality by ensuring skilled parturition, reducing postpartum complications and promoting safe motherhood. A substantial proportion of women in India give birth at home without any professional assistance and one in every sixth woman cites high out-of-pocket expenditure as a reason for choosing home-birth over institutional birth. A conditional maternity benefit program, Janani Suraksha Yojana (JSY), was launched in India to reduce the maternal care associated

mortality and morbidity burden. The aim of the project is to identify determinants of out-of- pocket expenditure on institutional delivery in two states of India with the highest and lowest

proportion of institutional delivery, namely, Kerala and Nagaland respectively, and analyze the differential effects of the predictors in the two states. Methods: The study used data from the 4th National Family Health Survey (NFHS-4) conducted in 2015-16. Secondary data analyses were conducted using a two-part hurdle model consisting of multivariable logistic regression to model the probability of incurring out-of-pocket expenditure on institutional delivery for a binary outcome (zero versus any out-of-pocket expenditure) and generalized linear model with log link and gamma distribution to understand independent variables associated with a continuous outcome (non-zero positive amount of out-of-pocket expenditure) among those women who made a payment. Results: In Kerala, 2,126 women gave birth in a health care facility in the five years preceding the survey and 78.7% paid out-of-pocket for institutional delivery. Women who gave birth in a private health care facility (OR = 2.52, 95% CI = 1.90; 3.34), had a Caesarean delivery (OR = 1.39, 95% CI = 1.07; 1.79) and were JSY beneficiaries (OR = 1.38, 95% CI = 0.96; 1.96) had higher odds of making a payment. Among women who paid, the mean expenditure was higher among women who obtained higher education (e" = 1.17, 95% CI = 1.05; 1.30), had Caesarean delivery (e" = 1.42, 95% CI = 1.30; 1.54), gave birth in a private health care facility (e" = 2.75, 95% CI = 2.39; 3.16), belonged to OBC caste category (e" = 1.15, 95% CI = 0.97; 1.36) or other caste category (e" = 1.32, 95% CI = 1.12; 1.57) and belonged to middle wealth index group (e" = 1.42, 95% CI = 1.11; 1.80) or rich wealth index group (e" = 1.69, 95% CI = 1.34; 2.16). The mean expenditure was lower among JSY beneficiaries (e" = 0.69, 95% CI = 0.56; 0.84). In Nagaland, 1,081 women gave birth in a health care facility in the five years preceding the survey and 70.9% paid out-of-pocket for institutional delivery. Women who resided in rural areas (OR = 1.51, 95% CI = 1.04; 2.19), obtained higher education (OR = 1.22, 95% CI = 0.77; 1.93), gave birth in a private health care facility (OR = 1.41, 95% CI = 0.90; 2.20), belonged to middle wealth index group (OR = 1.35, 95% CI = 0.89; 2.03) had higher odds of making a payment. The ‘other caste’ category of the variable ‘caste’ had a problem of sparse data; hence, the model could not produce meaningful estimates for it. Among women who paid, the mean expenditure was higher among women with higher education (e" = 1.15, 95% CI = 0.91; 1.45), who had Caesarean delivery (e" = 2.63; 95% CI = 2.20; 3.16) and who gave birth in a private health care facility (e" = 2.59, 95% CI = 2.14; 3.10). The mean expenditure was lower among JSY beneficiaries (e" = 0.82, 95% CI = 0.66; 1.02). Conclusion: The study found some similar and some differential patterns for socio-demographic and obstetric predictors of out-of-pocket expenditure on institutional delivery in the states of Kerala and Nagaland. It is recommended to adjust the JSY cash incentives based on several socio-economic and obstetric differentials.