India has made significant progress in reducing maternal mortality ratio, which decreased from 370 to 145 per 100,000 live births between 2000 and 2017 . This remarkable achievement can be attributed to the country’s concerted effort during the Millennium Development Goal (MDG) era to increase women’s access to maternal health services, in particular the initiative to increase institutional births . Institutional births (both at public and private institutions) rose from 35 percent in 2005 to 79 percent in 2016 . However, the rate of maternal mortality decline was inadequate to meet the global MDG target and India is still a significant contributor to global maternal deaths. Indeed, India has the second highest number of maternal deaths in the world, second only to Nigeria, accounting for 12% of global maternal deaths in 2017 . Projections indicate that India is off track to meet the sustainable development goals (SDG) target for maternal mortality ratio of 70 deaths per 100,000 live births by 2030 .
The renewed commitment to reduce maternal and infant mortality ratios under the SDG and the amount of resources the government is investing to improve maternal and child health outcomes underscore the need to understand the dynamics of maternal and child health care utilization beyond simply focusing on institutional births. Encouraging women to give birth in health facilities, where the delivery will be assisted by a skilled birth attendant, has been an important global strategy to reduce maternal and perinatal deaths in low- and middle-income countries [6-8]. Pregnant women require professional attention not only during the period of delivery but throughout the pregnancy and postnatal period. Evidence supports that, while most of the deaths during childbirth and post-natal period are due to preventable causes, institutional birth on its own does not provide adequate support to prevent maternal deaths due to pregnancy complications [9-11]. What is needed is the continuum of care  for maternal, newborn and child health whereby pregnant women are provided with antenatal care leading to institutional delivery, which is then followed by postnatal care for both mother and child.
The Indian government in 2005 rolled out a conditional cash transfer program – known as Janani Suraksha Yojana (JSY) - to increase pregnant mothers’ access to maternal and child healthcare services with the aim of reducing maternal and neonatal mortality . The program was implemented across 18 high-focus and 10 low-focus states, which were distinguished based on differences in economic and maternal and child health (MCH) indicators. Under the JSY program, pregnant women were given cash incentives to deliver in institutions. All pregnant women in high focus states were eligible to receive 1400 Indian rupees upon delivery while women below the poverty line and those belonging to scheduled castes and tribes in low focus states were eligible to receive 1700 Indian rupees . Women below the poverty line (who had registered under the program) would also receive 500 Indian rupees to deliver at home with the assistance of trained professionals. Moreover, female community health workers (known as Accredited Social Health Activists (ASHA)) were paid to facilitate antenatal checkups, immunization of newborn babies and postnatal visits . The program was designed to address inequality in access to maternal and child health care by mitigating financial barriers that thwarted poor women from accessing institutional care .
Several studies evaluating the JSY program had concluded that the program had been successful in increasing institutional births in India [16, 17]. However, there is evidence that inequality in institutional births has persisted  and that the level of maternal healthcare utilization, especially among the poor, continues to remain low. Saradiya and Singh  suggested that recipients of JSY still incur a significant out-of-pocket expenditure on maternal care despite the objective of the program to reduce the financial burden on poor pregnant women. Vellakkal et.al.  similarly argued that ‘….the cash incentive played a lesser role in motivating the people to opt for institutional delivery care because of the higher associated opportunity costs’ (p. 61) including expenses on food and transport and forgone spousal wages. A study assessing maternity expenditure in India using data from 2014 found that the average spending on maternity care was ten times higher than the amount obtainable under JSY scheme . High cost is a major deterrent to service utilization among the poor [19, 20] and out-of-pocket expenditure may impose catastrophic burden on poor households further plunging them into poverty .
Given that out-of-pocket payments to finance healthcare could be catastrophic to poor households [18, 21], World Health Organisation (WHO) has identified universal health coverage as a key strategic priority for achieving equity in access and utilisation of healthcare. Following this both developed and developing countries around the world while have adopted UHC in different forms depending on their socio-cultural context and the stages of economic development. They use different financial mechanisms such as: private health insurance, public health insurance, social health insurance, community health insurance or a mixed of all or different combinations of health insurance schemes for achieving UHC. Historically India has adopted different mechanisms in different sectors however, the first pan Indian tax based public health insurance scheme: Rastriya Swasthya Bima Yojana (RSBY) was rolled out in 2008. RSBY is mandated to cover all territories of India and occupational groups  with the aim to protect poor Indian households from financial risks due to hospitalization. The insurance covers secondary inpatient care provided at community health centers, district hospitals, and medical colleges. Only poor households “Below the Poverty Line (BPL)” are covered under the insurance and they can receive up to 30000 Indian rupees (per annum) for hospitalization. Malhi et.al.  note that out of 65 million families who had been targeted for coverage, 41 million had enrolled by September 2016.
This study investigated if the introduction of RSBY in 2008 as a pan-Indian health insurance scheme improved the overall utilization of maternal and child healthcare (MCH) services in terms of improving their access to the ‘continuum of care’ for maternal, newborn and child health. Against the backdrop of significant improvement in institutional births during this period, the study cross-examined if pregnant women in 2012, compared to 2005, had improved in utilizing a wider coverage of antenatal care leading to institutional births, followed by postnatal care for both mother and child. The period of study (2005 - 2012) also coincided with the rolling out of the JSY scheme, which was intended to boost institutional births and women’s engagement with maternal care services. While this study did not have information on those women who had accessed JSY, it is highly likely that JSY would have influenced institutional births during this period. We used information on women who gave birth both before and after the introduction of the RSBY. RSBY covers maternity benefits and all expenses related to delivery at the hospital, including transportation charges of 100 rupees paid to the beneficiary . In particular, hospitals will be paid 2500 rupees for natural delivery and 4500 rupees for C-section delivery, but prenatal expenses are not covered under the scheme. The maternity benefits may encourage more women to take-up institutional births. Moreover, if the scheme reduces the household overall out-of-pocket expenditure on healthcare (which was the goal of the government in rolling out the public insurance scheme in the first place), then it would help pregnant women (enrolled in the program) to cover expenses related to antenatal care and other MCH services which are not covered by RSBY. Whereas the literature is rife with articles analyzing the effect of the JSY cash transfer program on maternal care [14-16], the effect of the public health insurance (RSBY) on MCH service utilization has not been investigated. Studies on RSBY have mainly focused on patterns of enrollment to the insurance scheme, its utilization and effect on out-of-pocket expenditure of households [20, 22-25].
We used the 2005 and 2011-2012 rounds of the Indian Human Development Survey (IHDS) for our analysis. An important difference between the two rounds of the IHDS was the introduction of the RSBY insurance scheme across India. The insurance and financial assistance schemes available in 2005 included private insurance schemes, various public sector schemes offered to employees, specific state government insurance schemes offered to residents in their states, and other schemes focussed on specific groups (such as JSY for pregnant women). RSBY was added on top of these various schemes in 2008. We matched women who had given birth before each of the two survey rounds to examine how health insurance had influenced their utilization of MCH services over time. Since the publicly funded health insurance scheme was not rolled out until 2008, those women whose delivery was recorded in the 2005 round had not benefitted from RSBY. However, the 2005 IHDS data captured if surveyed households had availed themselves of private health insurance. Our analysis was intended to show if health insurance, in general, has been a significant factor in increasing women’s MCH utilization and, in particular, if the public insurance funded by the government has been effective compared to private health insurance.
Another objective of the paper was to investigate the relationship between maternal and child health care utilization and empowerment of women. The wider literature showed that giving women more decision-making power in the household leads to better educational and health outcomes for children since women have been shown to allocate more household resources towards children [26-31]. Similarly, we would expect empowered women to utilize more MCH services given their role as primary caregivers of children. However, women continue to have little household decision-making authority in many developing countries including India. We constructed indexes to measure empowerment of women using principal component analysis and determined the extent to which changes in maternal empowerment have affected MCH utilization.
Our study combined three indicators of maternal and child health outcomes – institutional births, antenatal and postnatal checkups – and examined how the behavior of women in accessing these services have changed over time. It is important to study how MCH utilization has changed over time in India, especially in the era when the Indian government has invested considerable resources in the sector, including launching the conditional cash transfer program (JSY) and rolling out a public health insurance scheme (RSBY) to incentivize women to access MCH services.