On paper, Sanju, a seven-months pregnant woman who lives in Lokhava village in Uttar Pradesh’s Balrampur district, has ample support from the Indian government. Under the National Food Security Act, she is legally entitled to Rs 6,000 as maternity assistance to be given in instalments during her pregnancy and after childbirth. In addition, under the Janani Suraksha Yojana, an intervention programme for safe motherhood, she should get Rs 1,400 for delivering in a government hospital.

The cash incentives are meant to ensure that women get medical care and nutritional support at a time when they badly need it. In a state such as Uttar Pradesh, where 258 women die during childbirth for every 1,00,000 live births, such support can go a long way in bringing down maternal mortality as well as improving the health and survival chances of their babies.

But Sanju does not stand a chance of getting this help – under the Pradhan Mantri Matritva Vandana Yojana, which is still not operational, the government has limited maternity assistance to the birth of the first child. Sanju is pregnant for the third time. As far the cash incentive for delivering in hospital, that will depend on whether she is able to make it to the nearest hospital, which is about 40 km away.

No wonder schemes for pregnant women are not making a significant difference in Uttar Pradesh. Only seven of 10 women in the state have institutional deliveries. In Balrampur, an impoverished district in the Himalayan foothills, this number is even lower at three. This, despite the Janani Suraksha Yojana running for 12 years.

What explains the failure? This report, the second in a series on the underlying causes of high infant and maternal mortality in Uttar Pradesh, tries to answer this question.

‘Flagrant violation of law’

On December 31, in a special address to the nation, Prime Minister Narendra Modi announced that his government would give maternity assistance of Rs 6,000 to every pregnant woman in India. This was not a new scheme – Modi was merely promising to implement the long overdue provision in the National Food Security Act of 2013, which mandates universalised maternity benefits, building on a pilot project that had been running in 53 districts since 2010.

A year later, however, women are yet to receive the maternity assistance. In August 2017, the government released the guidelines for its maternity assistance scheme, Pradhan Mantri Matritva Vandana Yojana, but it is still not operationalised it.

Worse, the scheme limits maternity assistance to the first birth by a woman. Under the National Food Security Act, women are eligible for maternity assistance for every birth. The Indira Gandhi Matritva Sahyog Yojana, launched by the previous government in 53 districts, restricted the assistance to two births. But the present government has further narrowed this down.

The government also announced that assistance under the new scheme would be only Rs 5,000 – less than the Rs 6,000 mandated by the National Food Security Act. This would be given in three tranches – Rs 1,000 at the time of registering with a local public hospital, Rs 2,000 after completing four antenatal check-ups there, and Rs 2,000 after her newborn child is immunised. The government clarified that only women who had already enrolled and received the first instalment under the pilot programme in 53 districts would get Rs 6,000 on average between the existing and new schemes.

A group of economists have now written to Finance Minister Arun Jaitley, asking for the budget for maternal entitlements to be increased as per the National Food Security Act. They say the Union Budget 2017-18 provision for the programme, which is Rs 2,700 crores, is barely a third of what is required. In the letter, they say:

“Maternity benefits of Rs 6,000 per child are a legal entitlement of all Indian women (except those already covered in the formal sector) under the National Food Security Act 2013. For more than three years, the central government did virtually nothing about this. On 31 December 2016, Prime Minister Narendra Modi finally announced that maternity benefits would be provided very soon. One year later, however, (1) the new scheme framed for this purpose (PMMVY) is yet to be operationalised, (2) the provision made for it in the Union Budget 2017-18 (Rs 2,700 crores) is barely one third of what is required based on NFSA norms; and (3) in flagrant violation of the Act, PMMVY restricts the benefits to Rs 5,000 for just one child per woman.”

In Uttar Pradesh, where women have an average of three children, giving maternity benefits only for the delivery and care of the first child deprives most pregnant women of their legal entitlements, say health workers.

Dipa Sinha, an assistant professor at Ambedkar University in Delhi who is part of the group that has written to the finance minister, pointed out that since Uttar Pradesh has a much higher total fertility rate than a state like Tamil Nadu, there will be more women having their second, third or fourth children in Uttar Pradesh than in Tamil Nadu. Therefore, the scheme when implemented, will benefit a larger proportion of women in Tamil Nadu having their first children as compared to women in Uttar Pradesh who had their first children before these benefits were announced.

“By restricting the scheme to first birth, the government has additionally marginalised women,” said Sinha.

Aasma, a resident of Gulhariya village in Bahraich, lost her first child within days of birth. Now a mother of four, she is pregnant for the sixth time. She will not be eligible for the maternity assistance.

Sanju, left, is pregnant with her third child. Photo credit: Priyanka Vora

Hurdles in hospital deliveries

While the maternity assistance remains merely a promise, the Janani Suraksha Yojana, launched in 2005, continues to underperform in Uttar Pradesh.

A major hurdle for a woman getting the benefits is actually getting to a hospital for an institutional delivery, which is the condition to receive Rs 1,400 under the Janani Suraksha Yojana. As reported in the first part of this series, Uttar Pradesh’s healthcare infrastructure is among the worst in India. For a population of 90,000, Balrampur has only three hospitals and 34 doctors (number of doctors sanctioned is 118). Women here have horror stories to tell. Mehroonah, 17, was keen to deliver in hospital and when she went into labour, she was bundled into an autorickshaw. “The baby’s head was coming out and she was born in the vehicle,” Mehroonah recalled, holding her daughter Gulfisa, who is a year old now.

The Uttar Pradesh government has instituted a free ambulance service, which picks up pregnant women and drops them home with the child after delivery. Mehroonah was not aware of the service. Health workers say the ambulances rarely reach on time. “The quality of the roads is poor which increases the time of travel,” said Dr RB Yadav, Bahraich district programme manager, National Health Mission.

In Balrampur, 70% women deliver at home. That is partly because none of the three hospitals have anaesthesiologists. “There is no anaesthesiologist in the entire district,” said Dr Neena Verma, a paediatrician who is also the medical superintendent of the women’s district hospital.

Sometimes, when Verma refers a woman to the hospital in neighbouring Bahraich, the family goes home instead of making the long journey to the hospital.

Another problem is corruption, which may actually be worsened by cash-incentive programmes. “As the nurses know that the woman will receive money from the government, they demand a higher bribe,” said Kumari Ramavati Bharti, who runs an aanganwadi in Risia block of Bahraich. “So many women instead go to private doctors or try their best to deliver at home to save money.”

Jibraeel, a resident of Balrampur, complained to the district's chief medical officer after a nurse at the district hospital demanded Rs 3,300 to deliver his sister-in-law's child. The child was stillborn.

Then, there is discrimination. “Both the helper and nurse in the delivery room were upper caste so they did not help a lower-caste woman who went into labour in the toilet,” said Verma, citing a recent case. “When the family came, the nurse and the helper instructed them [about how to conduct the delivery] and did not touch the patient.”

In view the large number of women who deliver at home, the government has made a provision of giving them Rs 500 for every child born at home. But most women in Balrampur’s villages complain they have not received any money. “There is a condition that the woman will be entitled to get Rs 500 only if the auxiliary nurse midwife performs the delivery,” said Shivendra Mani, Balrampur district programme manager of the National Health Mission. Mani said another hurdle is that most women do not have the necessary documents such as ration cards or bank accounts. This year, the department has transferred money to only eight women in Balrampur.

In Bahraich, Yadav said there have been no payments in the last three years.

The Aadhaar stumbling block

Many women who are eligible for benefits under the Janani Suraksha Yojana have not been able to access the money because of the government’s insistence on having an Aadhaar-linked bank account.

Having a bank account became mandatory in order to get monetary assistance in 2014-’15. Earlier, women used to be given their incentives in cash soon after delivery, but following complaints that middlemen were siphoning off the money, the government decided to route it directly to the women’s bank accounts. What it did not anticipate was the continuing difficulties faced by women to open and operate bank accounts.

Rubina, who delivered a child in a hospital in September 2016, could not get the Rs 1,400 benefit under the Janani Suraksha Yojana scheme because she does not have a bank account. “My husband does not allow me to open a bank account,” she said, referring to the practice of men restricting women’s access to money in order to have control over them. “I don’t have any identity proof. I have a voter card which my husband keeps with him.”

Rubina with her one-year-old child. She does not have a bank account. Photo credit: Priyanka Vora

The government has now introduced the additional requirement of an Aadhaar number, which must be linked to the pregnant woman’s bank account. The government has made the 12-digit biometric-based identity number mandatory for many social welfare schemes, arguing it can help identify beneficiaries accurately and plug leakage of funds.

But in the villages of Bahraich, this has been a recipe for chaos. Keen to get their welfare benefits, the villagers have made Aadhaar cards but at a huge cost. “Entire villages have been conned by people who come and take documents, click photographs but never return with the cards,” said Poonam Sharma, facilitator of accredited social health activists or ASHAs in Bahraich. When cards are delivered, often the photograph is missing, she said, showing such cards.

Outside the health department’s office in Balrampur, Zarina, who delivered a child about three and a half months ago at a primary health centre, said she was told to get a bank account and Aadhar card, if she wanted Rs 1,400 from the government. Zarina said she gave the Rs 500 she had saved for food and clothes for her child to a shopkeeper who applied for Aadhaar on her behalf, since she cannot read or write.

Fortunately, unlike those who have been conned, Zarina did get her Aadhaar number. She also managed to open a bank account. But she is still waiting for the Rs 1,400 that the health workers had promised her. “I submitted everything and even went to the bank, but the bank says the government has not sent any money to me,” she added.

Since April 2017, more than 8,000 mothers in Balrampur have not received their incentives, according to an audit conducted by the health department. “We also don’t know what the problem is,” said Dr Ganshyam Singh, chief medical officer of Balrampur. “We have been told that either the women do not have bank accounts or their banks accounts are not linked with their Aadhaar numbers.”

Another problem, Yadav said, was that many bank accounts have been deactivated for being inactive. “We tried to help them open zero balance accounts, but banks want them to have some transactions,” he said.

Graphic: Anand Katakam, Manas Sharma