Cash for mothers

ALTHOUGH a Maternity Benefit Act has been in existence for over five decades, the vast majority of Indian women do not get any maternity entitlements as the legislation does not apply to the unorganised sector. The majority of working women in the country work until the last stages of pregnancy and get back to work soon after delivery to avoid loss of wages. In response to a long-standing demand for the universalisation of maternity benefits, the Government of India has finally come up with a scheme that purports to improve the health and nutritional status of infants and pregnant and lactating women. Realising that existing schemes have not holistically addressed the issues that compel women to work right up to the last stage of pregnancy and resume work soon after childbirth, thus endangering both themselves and their infants, the Ministry of Women and Child Development has proposed a pilot project based on a conditional cash transfer scheme in some 95 districts across the States and Union Territories. The government intends to universalise it.

Under the new conditional maternity benefit (CMB) scheme, which is called the Indira Gandhi Matritva Sahyog Yojana, a modest maternity benefit of Rs.4,000 will be given to every pregnant and lactating woman to partly compensate for the loss of wages. The money will be given in three instalments and will have to be used strictly for the mother's antenatal care and the baby's immunisation. Cash incentives will also be given to anganwadi workers and helpers to motivate them and ensure that the target group gets the benefit of the cash transfer. The overall responsibility of monitoring has been entrusted to the Integrated Child Development Services (ICDS). The pilot project will cover pregnant women of 19 years of age and above for the first two live births. The CMB scheme has been allocated some Rs.4,500 crore for the remaining part of the Eleventh Five Year Plan.

The main objective of the scheme, therefore, is to encourage women to get used to optimal infant- and young-child-feeding practices, including early and exclusive breastfeeding for six months, and make use of health care services. Social activists in the health sector argue that cash transfers can be made and the objectives achieved without imposing conditions. The system of conditional cash transfers in the area of maternal health is a departure from previous methods of encouraging women to access health entitlements. There has been some global experience, albeit mixed, of the success of cash transfer benefit schemes. They are conditional and contingent upon certain behaviour or action, usually investments in human capital such as sending children to school or bringing them to health centres on a regular basis. The success of the scheme will depend on supply side factors and not just the demand. In the Indian context, such schemes have been targeted more towards the individual rather than the household.

While the objective is laudatory, social activists feel that it is important for the government to draw lessons, good and bad, from cash transfer schemes that exist in a few States. In May, the Public Health Resource Network, the M.S. Swaminathan Research Foundation and the Tamil Nadu chapter of the Forum for Creche and Child Care Services carried out a study of the Tamil Nadu government's Dr Muthulakshmi Maternity Benefit Scheme and pointed out that the national scheme would do well to learn some lessons from the Tamil Nadu experience. The primary data for the study were collected from Kancheepuram and Dharmapuri districts, which rank second and 29th respectively in terms of the Human Development Index, according to the State Planning Commission's report in 2001.

The Tamil Nadu experience, the authors of the study say, emerges in the context of the long tradition of making provision for welfare measures in the post-Congress regimes of the Dravidian parties. The welfare measures, with their emphasis on the social sector, have included scholarships for girls and Dalit students, pensions for widows and aged people, marriage support and grants and, the jewel in the crown, the Midday Meal Scheme. It was in such a context that a modest child assistance scheme, named after Dr Muthulakshmi Reddy, was launched in 1987. Its beneficiaries were offered Rs.300 to cover the expenses of childbirth. The amount was enhanced to Rs.500 in 1995. An independent study in that period revealed that the uptake was low for reasons ranging from too much paperwork, and the need for repeated visits to delays, transport expenses and even corruption. Many of the women questioned in that study revealed that the amount was not worth the trouble involved in getting it, so many months after childbirth.

Meanwhile, in 1995-96, the Central government came out with the National Maternity Benefit Scheme, which was subsumed into the Janani Suraksha Yojana of 2005, in which the cash transfer was entirely contingent on mothers opting for institutional deliveries. Later, after activists protested, women giving birth at home were also given cash assistance, though a smaller amount. In 2006, the Tamil Nadu scheme was modified into a maternity support scheme; it was no longer a one-time childbirth support scheme. In its new avatar, Rs.6,000 was disbursed in two instalments. Even this amount was inadequate, say the authors of the May study, and the Central scheme plans to give Rs.2,000 less. The cash transfer was conditional in that it was provided only for two deliveries. Since 2009, the money is being paid in a single instalment, after childbirth, thus subverting the objective of nutritional support during the last phase of pregnancy. The good part of the scheme is that it is fairly realistic and liberal in defining poverty.

In contrast, the Central scheme has many more conditionalities in its structure. In a letter to the Ministry, the Working Group for Children under Six (constituted by the Planning Commission under the Eleventh Five Year Plan) cautioned that conditional cash transfers were the most effective when the supply side problems were already taken care of because people who needed cash transfers the most were likely to face such problems. The group expressed concern over the fact that there were conditions with respect to services such as immunisation, facilities for which may not even exist in tribal and far-flung areas. The group recommended that the conditions be removed for now and that the cash transferred focus on intensive change with respect to infant- and young-child-feeding practices, including training of the anganwadi workers and helpers who would deliver the service. The group also suggested that the eligibility criterion of 19 years for the cash transfer be removed. It argued that it was the children of underage mothers who suffered a greater risk of having low birth weights and being malnourished. The group reminded the Ministry of a Supreme Court order of 2007 which said that benefits under the National Maternity Benefit Scheme should be given irrespective of the number of children and the age of the mother. It also suggested that the amount be enhanced to six months of wage compensation at minimum wage levels to make it equitable to what women got in the organised sector, which was recently enhanced in the Sixth Pay Commission, with additional benefits to Central government employees.

What the Tamil Nadu study found was that most women who received the benefit after delivery used it for medical expenses and food and not for frivolous items. This pattern of expenditure indicated to what extent people were dependent on ready cash for medical expenses and food and how crucial these things were to the lives of these women, especially after childbirth. A good number of the women interviewed felt that there should be no delay in payment, that it would suit them better if the money was given in two instalments, that the entitlement should be more than Rs.6,000, that there should be no conditions attached, and, most important, that it should be universalised. The two-child norm seemed to be operating in devious ways as the study found that the village health nurse (VHN) and the auxiliary nurse midwife (ANM) were convinced that the scheme was meant only for mothers with one or two children. The VHNs and the ANMs also said they were overworked and felt that the government ought to recruit more of them. This demand for more personnel is likely to come up in the Central scheme as well despite the incentive given to anganwadi workers and helpers whose workload will definitely increase with this additional responsibility. The Tamil Nadu experience showed that the scheme helped to promote breastfeeding as women were able to take rest and eat nutritious food. This highlights the importance of enhancing the present ceiling and making it equivalent to six months of wages post delivery.

Quoting International Labour Organisation (ILO) studies, the report makes some comparisons on parental leave worldwide. European countries were found to be way ahead in providing parental leave and benefits, with Sweden and Estonia on top of the list. While Sweden provides a 16-month paid leave per child, in the Americas it was only Canada that provided benefits to parents for up to 50 weeks. The worst record was in Asia and Africa, where on an average, according to the ILO, maternity benefits only extended to 12 weeks or even less.

Maternal under-nutrition has finally come to be seen as a major challenge in government circles. Government statistics point out that 35.6 per cent of the women in the country have a low body mass index, and child marriage, early childbearing and frequent pregnancies adversely affect maternal nutritional status. Around 30 per cent of women aged 25-49 years give birth before the age of 18 years. According to the National Family Health Survey-3 (NFHS-3), 58 per cent of the women are married before the legal age of 18 years. The prevalence of anaemia in married women increased from 52 per cent at the time of NFHS-2 to 56 per cent at the time of NFHS-3. According to NFHS-3, 69.5 per cent of the children between six and 59 months have anaemia. The government now admits that the anaemia situation has worsened among women and children.

Problems on the supply side continue to remain. Fewer than half of the women receive any antenatal care during the first trimester of pregnancy, some 22 per cent have their first visit during the fourth month of pregnancy, and just over half of the mothers have three or more antenatal care visits. The figures for immunisation are equally stark. Fewer than 44 per cent of the children in the age group of 12-23 months were fully vaccinated at the time of survey against the six major childhood diseases: tuberculosis, diphtheria, pertussis (whooping cough), tetanus, polio and measles.

For any maternity benefit scheme to succeed, first of all, pregnancy should not be viewed as a disease and children should not be seen as a burden and two-child norm should not operate, in overt or covert forms. Schemes should not be linked to institutional deliveries because many women continue to give birth at home. It is also not possible to bring down maternal mortality and improve the rates of breastfeeding and immunisation merely by giving people cash; this has to be matched with expanded budgetary allocation for health care and improved health infrastructure.