Maternity entitlements are neglected in states like Jharkhand, M.P. and U.P., reveals JABS survey (2019)
Among other things, the JABS survey shows that pregnant women’s basic needs for nutritious food, proper rest and health care are rarely satisfied. It should be noted that the Jaccha-Baccha Survey (JABS i.e. mother-child survey) was conducted by student volunteers in six states of north India: Chhattisgarh (survey month: June 2019), Himachal Pradesh (survey month: July 2019), Jharkhand (survey month: October 2019), Madhya Pradesh (survey month: June 2019), Odisha (survey month: June 2019) and Uttar Pradesh (survey month: June 2019). The survey for most states took place in mid-2019, whereas the survey for Jharkhand happened in October 2019.
About 12 villages in each state on average were covered for the survey: fewer (eight) in Jharkhand, and more (nineteen) in Himachal Pradesh where anganwadis tend to have a small catchment area. In total, 706 women were interviewed in six states: 342 pregnant women and 364 nursing women.
• The authors of the paper have calculated that the actual budgetary allocation for maternity benefit scheme was lower than the Budget Estimates for the years 2010-11, 2011-12, 2012-13, 2013-14, 2016-17, 2017-18, 2018-19, 2019-20 and 2020-21. The estimated allocation required for universal coverage of Rs. 6,000/- per child as maternity entitlements is computed to be Rs. 14,000 crore.
• In 2017, the Central Government formulated a new maternity benefit scheme under Section 4 of NFSA, which was named as Pradhan Mantri Matru Vandana Yojana (PMMVY). Prior to PMMVY, a pilot scheme called Indira Gandhi Matritva Sahyog Yojana (IGMSY), launched in 2010, was operational in 53 districts. It gave benefits of Rs. 4,000 per child. The IGSMY could not be scaled up to 200 districts from 53 districts in 2015-16 and all districts in 2016-17, as was desired by the Ministry of Women and Child Development (MoWCD) in its affidavit in the Supreme Court dated 30th October 2015, because of low budgetary allocation.
• The PMMVY guidelines and draft Rules, released in August 2017, mentioned that maternity benefits were restricted to “the first living child”, which was a glaring violation of the National Food Security Act. Even for the first live birth, maternity benefit was restricted to Rs. 5,000 per child (in three instalments), instead of Rs. 6,000 per child, and has been subject to various conditions.
• The total number of PMMVY beneficiaries who received at least one instalment was 11.1 lakh in 2017-18, which increased to 65.4 lakh in 2018-19 and further to 91.2 lakh in 2019-20. The total number of PMMVY beneficiaries who received the third instalment was 31.9 lakh in 2018-19, which increased to 55.8 lakh in 2019-20.
• The estimated PMMVY coverage (i.e. received at least one instalment) as a proportion of first births was 10.0 percent in 2017-18, 57.0 percent in 2018-19 and 78.0 percent in 2019-20. The estimated PMMVY coverage (i.e. received third instalment) as a proportion of first births was 28.0 percent in 2018-19 and 48.0 percent in 2019-20.
• The estimated PMMVY coverage (i.e. received at least one instalment) as a proportion of all births was 5.0 percent in 2017-18, 28.0 percent in 2018-19 and 39.0 percent in 2019-20. The estimated PMMVY coverage (i.e. received third instalment) as a proportion of all births was 14.0 percent in 2018-19 and 24.0 percent in 2019-20.
• PMMVY coverage fell in 2020-21, when the country was hit by the Covid-19 pandemic. According to the 2021-22 Union Government Budget documents, actual PMMVY expenditure in 2020-21 was just Rs. 1,300 crore as against a budgetary allocation of Rs. 2,500 crore. The actual expenditure was around Rs. 2,300 in 2019-20.
• It has been found in the sample households for the JABS survey that little attention was being paid to the special requirements during pregnancy i.e. good food, extra rest and health care. Often, family members or even women themselves had little awareness of these special needs. For instance, 48 percent of pregnant women and 39 percent of nursing women in Uttar Pradesh (U.P.) had no idea whether or not they had gained weight during pregnancy. Similarly, there was little awareness of the need for extra rest during and after pregnancy.
• A little over one-fifth (i.e. 22.0 percent) of the nursing women said that they had been eating more than usual during their pregnancy, and just 31 percent revealed that they had been eating more nutritious food than usual. The most commonly reported reason for not eating more is that pregnant women often feel unwell or lose appetite. The proportion of nursing women who reported eating nutritious food (e.g. eggs, fish, milk, fruit) “regularly” during pregnancy was less than half in the sample as a whole, and just 12 percent in U.P. The general practice seems to be for women to continue eating more or less as usual during their pregnancy.
• The JABS survey finds that the proportion of pregnant women who were eating less during pregnancy was 49 percent, eating more during pregnancy was 23 percent, eating nutritious food more often during pregnancy was 24 percent and eating nutritious food daily during pregnancy was 22 percent.
• It has been found in the JABS survey that the proportion of nursing women who were eating less during pregnancy was 47 percent, eating more during pregnancy was 22 percent, eating nutritious food more often during pregnancy was 31 percent and eating nutritious food every day during pregnancy was 20 percent.
• Nearly 26 percent of pregnant women reported swollen feet during pregnancy, 19 percent of them reported impairment of daylight vision and 8 percent of them reported convulsions. Among nursing women, as many as 49 percent reported at least one major symptom of weakness during pregnancy. Almost 41 percent of nursing women reported swollen feet during pregnancy, 17 percent of them reported impairment of daylight vision and 9 percent of them reported convulsions.
• The proportion of pregnant women who worked on family farms during pregnancy was 18 percent, had no one to help with housework during pregnancy was 26 percent and felt they did not get enough rest during pregnancy was 30 percent.
• The proportion of nursing women who worked on family farms during pregnancy was 20 percent, had no one to help with housework during pregnancy was 21 percent, felt they did not get enough rest during pregnancy was 38 percent and were able to take complete rest before delivery was 37 percent. In other words, almost two-thirds (63 percent) of the nursing women said that they had been working right until the day of delivery.
• Almost 34 percent of pregnant women and 30 percent of nursing women faced serious problems during pregnancy on account of lack of money.
• About 12 percent of nursing women delivered their child at home. Nearly 30 percent of households (with nursing women) had to borrow or sell assets to meet delivery expenses.
• The proportion of pregnant women who received at least one health check-up from the local anganwadi centre (AWC) or primary health centre (PHC) during pregnancy was 74 percent, tetanus shots from the local AWC or PHC during pregnancy was 84 percent and received iron and folic acid tablets from the local AWC or PHC during pregnancy was 74 percent.
• The proportion of nursing women who received at least one health check-up from the local AWC or PHC during pregnancy was 86 percent, tetanus shots from the local AWC or PHC during pregnancy was 96 percent and received iron and folic acid tablets from the local AWC or PHC during pregnancy was 93 percent.
• The proportion of eligible pregnant women who applied for PMMVY was 50 percent. The proportion of eligible nursing women who applied for PMMVY was 72 percent.
• The JABS survey has found that the average weight gain during pregnancy was 7.0 kg (just 4 kg in U.P.). Poor diets contribute to low weight gain during pregnancy. Even these figures are likely to be overestimates, as they exclude women who did not know their weight gain at all (i.e. 26 percent of all nursing women). Some women were so light to start with that they weighed less than 40 kg at the end of their pregnancy.
• Existing literature indicates low weight among pregnant women in India, reflecting both chronic undernourishment and low weight-gain during pregnancy. The weight of Indian women at the end of their pregnancy is extremely low by international standards, even compared with poorer countries in South Asia and Sub-Saharan Africa. Low weight of pregnant women is associated with low birth-weight of babies, and the latter, in turn, with stunting and other impairments later in life.
• Two signs of recent improvement in maternal care services are high rates of institutional delivery and widespread use of public ambulance services. Institutional deliveries, actively promoted from 2005 onwards under the Janani Suraksha Yojana (JSY), have become the norm in most of the JABS states; one notable exception is Uttar Pradesh, where 35 percent of recent deliveries had taken place at home. The use of ambulance services, a more recent development, is also growing rapidly – a majority of nursing women had used them at the time of delivery, just by dialling “108”. Some had to pay small charges – Rs. 58 on average.
• The JABS survey indicates that for the majority of nursing women the place of delivery was public health institutions (81 percent), followed by home -- in-laws or maika i.e. parents’ home (12 percent) and private health institutions (7 percent).
• The JABS survey has found that the majority of nursing women have found the attitude of the staff at institutions of delivery was friendly and helpful (61 percent), followed by somewhat helpful (17 percent), indifferent (10 percent), careless (3 percent), and rude and hostile (8 percent).
• Existing literature suggests that small ailments easily become a major burden, in terms of pain or expenses or both. At the time of delivery, women are often sent to private hospitals when there are complications. A significant minority also report rude, hostile or even brutal treatment in the labour room, corroborating recent studies of “labour-room violence” in India.
• The JABS survey among nursing women shows that the amount spent on delivery at public institutions was Rs. 3,643, delivery at private institutions was Rs. 45,524, delivery at home was Rs. 1,697 and average delivery cost was Rs. 6,409.
• The JABS survey among nursing women indicates that 60 percent of them used the ambulance service for delivery, 12 percent of them tried the ambulance service without success and 28 percent of them did not try for ambulance service.
• The JABS survey among nursing women indicates about 86 percent of them received at least one health check-up, 96 percent of them received tetanus shot, 93 percent of them got iron and folic acid tablets, 92 percent received food supplements, three-fourth of them received advice related to pregnancy/ diet/ delivery and 71 percent of them received post-natal check-up.
• The JABS survey among nursing women reveals that 61 percent did not have any health insurance. Among those nursing women having health insurance, only 14 percent of them had Rashtriya Swasthya Bima Yojana (RSBY), 9 percent of them had Ayushman Bharat, 11 percent of them had state health insurance scheme and 4 percent of them had others.
• JABS survey shows that women who spend some time at their parents’ home around the end of their pregnancy (a common but far from universal practice in north India) seem to have a better chance of getting ample rest.
• According to the paper, a fairly strong association emerges with indicators of good nutrition and especially rest, even after controlling for other variables and exploring alternative specifications. Aside from that, weight gain is positively associated with education and economic status, as is expected, and negatively associated with casual labour as a primary occupation. These are just statistical associations, but they are consistent with the notion that weight gain is strongly influenced by factors that are within reach of public action.
• The JABS survey differentiate leaders (i.e. Chhattisgarh, Himachal Pradesh and Odisha) and laggards (i.e. Jharkhand, Madhya Pradesh and Uttar Pradesh) among states in terms of social policy, from health and education to nutrition and social security. For example, Himachal Pradesh is an exception among the six JABS states due to its relatively good public services including maternal care. Women in Himachal Pradesh were found to be relatively well-off, well-educated and self-confident. Their predicament was much better than other states, with, for instance, an average weight gain in pregnancy of more than 11 kg.
• The authors of the paper have found signs of hope in Odisha. Odisha has its own maternity benefit scheme which is called the Mamata scheme. This scheme covers two births, not one, and seems to work relatively well: among the nursing women interviewed, 88 percent of those who were eligible for Mamata had applied, and three-fourth of those who had applied had received at least one instalment. Women’s awareness, understanding and utilisation of the scheme was much higher for Mamata in Odisha than for PMMVY in other states.
• In Odisha, eggs are regularly provided in the anganwadi centres. Not only do children aged 3-6 years get an egg five times a week with their midday meal, eggs are also distributed as “take-home ration” (THR) for younger children as well as pregnant and nursing women. This policy, also in place in a few other states, is yet to be adopted more widely. In some states, including Odisha, eggs are also on the menu in primary and upper-primary schools.
• The JABS survey shows that the reach of the Integrated Child Development Services (ICDS) scheme is also relatively good in Odisha, with near-universal coverage of basic services (health check-up, tetanus injections, iron and folic acid tablets, food supplements, etc.) among pregnant and nursing women registered at the anganwadi. The wide reach of ICDS services in Odisha is also corroborated by the findings of the fourth National Family Health Survey (NFHS-4), conducted in 2015-16: in rural areas, 91 percent of pregnant women reported receiving some services from the local anganwadi. This includes supplementary nutrition (90 percent), health check-ups (86 percent), and health and nutrition education (82 percent).
• Odisha is the only sample state where a majority of the respondent households were covered under some form of health insurance – either a national scheme (Rashtriya Swasthya Bima Yojana or its successor, Ayushman Bharat), or the state’s own health insurance scheme (Biju Swasthya Kalyan Yojana, launched in 2018). On this, again, the findings of the JABS survey are consistent with NFHS-4 data: 52 percent of rural households in Odisha had at least one member covered by a health insurance scheme in 2015-16. Among these households, 42 percent were covered by the state scheme, and 64 percent by RSBY.
• In Chhattisgarh too, many signs of hope were found such as brightly painted anganwadis, breakfast for the kids, a pre-school education syllabus, collaboration between anganwadi and health workers, etc. Some of these initiatives are yet to make a difference, but there is an emerging trend of improvement at least, says the paper. The state has made sustained efforts to improve anganwadis and primary health care. This has been exhibited in joint health check-up and immunisation sessions involving the local Mitanin i.e. Accredited Social Health Activist (ASHA), anganwadi worker (AWW) and Auxiliary Nurse-Midwife (ANM). On top of that, Chhattisgarh is one of the few states that have started providing a cooked meal to pregnant and nursing women at the local anganwadi, which is a legal right under Section 4 of the NFSA.
• The laggard states in the JABS survey were Jharkhand, Madhya Pradesh and especially U.P. In Madhya Pradesh, the picture was not all bleak – the “model” (aadarsh) anganwadis were relatively good, and hopefully similar standards can be achieved everywhere in the state. Almost every nursing woman there had delivered in a public institution and used a public ambulance. The general predicament of pregnant and nursing women, however, was not much better in Madhya Pradesh than in Jharkhand or U.P.
• U.P. is the usual straggler, with abysmal socio-economic conditions, dismal services and abominable corruption, finds the paper. The lives of pregnant women in Himachal Pradesh and U.P. are polar opposites. In U.P., their predicament is really grim. Only 15 percent of nursing women there had been eating more nutritious food than usual during their last pregnancy, just 64 percent had at least one health check-up, and a majority reported lack of adequate rest. All the anganwadis in the U.P. sample (for the JABS) were closed at the time of the survey – ostensibly because of the school holidays. Women and children disliked the panjiri (ready-to-eat mixture) being distributed as THR, if they ate it at all. No food was ever cooked at anganwadis, even for children in the age group of 3-6 years. Pregnant women, largely left to their own devices, were struggling with the worst possible hardships and pains. Aches, weakness and lethargy were recurring themes in conversations with respondents from U.P. Teenage pregnancies, sometimes ending in a stillbirth or infant death, were not uncommon. Many women in U.P. were struggling to meet their most basic needs, sometimes working for wages late into their pregnancy or soon after delivery. The general disempowerment of women within the family was very stark in U.P. Conversations with the respondents were often interrupted by or overseen by overbearing in-laws. Some of them even taunted the respondent in front of the survey team.
• The findings of the JABS survey, including regional contrasts, are broadly consistent with NFHS-4 data. There is evidence of a serious problem in U.P., where, for instance, only 60 percent of women had been weighed during their last pregnancy (lowest figure among major Indian states) and 4 percent had received all recommended types of antenatal care (second-lowest, after Bihar). Himachal Pradesh, by contrast, fares much better than the national average across the board.
• Eight years after the National Food Security Act became law, the Central Government is yet to deliver one of its main responsibilities under the Act: payment of maternity benefits of Rs. 6,000 per child to all pregnant women. Even the meagre benefits under PMMVY (i.e. Rs. 5,000 for just one child), it turns out, are elusive: as mentioned earlier, PMMVY coverage was still quite patchy in 2019-20.
• The poor coverage of PMMVY is also confirmed by the JABS survey. Among nursing women eligible for PMMVY, only 28 percent had received the first instalment. The coverage of the Mamata scheme in Odisha is much better in every respect – awareness levels, application rates, and actual benefits. It is worth noting that except in Odisha, very few women in other states get anything before the end of their pregnancy.
• It should be noted that maternity benefits under PMMVY have been restricted to Rs. 5,000 for the first living child, which is a glaring violation of the NFSA. Maternity entitlements have also been restricted in other ways. Some women are deprived of PMMVY benefits because the child was born at home, for reasons that are not necessarily under their control. There were some cases where a second wife was denied PMMVY benefits, even for her first child, on the grounds that the first wife had already benefited from the scheme.
• The main restriction, of course, is that there are no benefits beyond the first live birth under PMMVY. This is an odd restriction, since India does not have a one-child policy. It is also discriminatory: there is no such restriction for women who work in the organised sector (like government jobs) and receive such benefits. This restriction has seriously undermined PMMVY, by reducing the number of women who have a stake in it. If maternity benefits were universal, as prescribed under the NFSA, it would be much easier for pregnant women to understand and claim their entitlements. Even extending maternity benefits to two children instead of one would make a major difference, as is illustrated by Odisha’s Mamata scheme.
• In order to get the meagre benefits under PMMVY, eligible women are required to fill a long form for each of the three instalments (the combined length was 23 pages at the time of the survey). They also have to produce their “mother-child protection” (MCP) card, Aadhaar card, husband’s Aadhaar card, and bank passbook, aside from linking their bank account with Aadhaar. Further, they also have to rely on the goodwill of the anganwadi worker and Child Development Project Officer (CDPO) to ensure that the application is filed online. This entire process is challenging, especially for women with little education. Among the nursing women in the JABS survey, 41 percent faced at least one major problem with the application process. Many were not even aware of PMMVY benefits at the time of the JABS survey.
• Online PMMVY applications and payments are often rejected, delayed, or returned with error messages for a variety of reasons, some of which have been revealed in the studies related to Aadhaar-enabled payments of welfare benefits in schemes and programmes such as pensions and the MGNREGA. Examples include: (a) incomplete information, (b) inconsistencies between Aadhaar card and bank passbook; (c) diversion of payment to a wrong person’s account. In cases of unsuccessful application or payment failure, there is no provision for informing the concerned women and explaining to them what needs to be done.
• The PMMVY application process is complicated to start with, according to the paper. About one-fifth of the respondents who had applied for PMMVY reported experiencing Aadhaar-related problems. In addition to this, there are Aadhaar-related problems at the payment stage (e.g. when payments are made using the Aadhaar Payment Bridge System) that were mostly beyond the respondents’ understanding, so that they did not attribute them to Aadhaar. Some of them were reported by anganwadi workers, who take care of application formalities on behalf of the women. Almost half of the AWWs had experienced similar problems themselves.
• PMMVY benefits (in contrast with Odisha’s Mamata scheme) also require verification of the husband’s identity, again based on his Aadhaar card. There were cases where women could not apply, or the application had been delayed, because of failure to produce the husband’s Aadhaar card. Some husbands did not have Aadhaar cards, some women were living with men to whom they were not married, or were single mothers. There were many cases where an application had been delayed or stalled because the applicant’s Aadhaar card still carried her parents’ address instead of her in-laws’ address.
• There are frequent inconsistencies of demographic information between a woman’s Aadhaar card and other documents such as her application form or bank passbook. Minor discrepancies or glitches (e.g. typos in Aadhaar number, misspelling of names, wrong date of birth on Aadhaar card, mismatch between Aadhaar card and other records, etc.) can all lead to a PMMVY application being rejected or delayed. In most cases, these errors creep in for no fault of the women concerned, but they are paying the price for it. Further, the steps required to make these corrections are not clearly defined or communicated.
• Problems often arise from the insistence on bank accounts being linked with Aadhaar. Many women could not open a bank account because they did not have Aadhaar; others faced difficulties because their bank account was not linked to Aadhaar, despite repeated attempts in some cases.
• There were other complications, including cases where even the anganwadi worker and/or bank official were unable to figure out what the problem was. Some women were asked for a bribe by the AWW or ASHA when their assistance was required to solve Aadhaar-related issues.
• In principle, there is a provision for applying without Aadhaar, but in practice, Aadhaar is considered to be mandatory. This creates serious problems for women who do not have Aadhaar, or lost their Aadhaar card, or find errors in their Aadhaar records.
• One should know that the ICDS programme plays a key role in the realisation of maternity entitlements. The anganwadi is the bridge that connects children under six as well as pregnant and nursing women with government services. Hot cooked meals are provided to children aged 3-6 years and are also supposed to be provided (under NFSA) to pregnant and nursing women. For children aged 6 months to three years, and for pregnant and nursing women, there is a provision of “take-home rations”. Anganwadis also deliver health services such as immunisation, iron supplementation and growth monitoring aside from pre-school education.
• Except in Uttar Pradesh, a large majority of children under six and pregnant or nursing women receive some ICDS services, including food supplements in most cases. In states like Chhattisgarh and Odisha, where ICDS is relatively well integrated with health services, health check-ups at the anganwadi have also become the norm for the same groups.
• Pre-school education, much neglected for a long time, is being taken more seriously recently. Barring U.P., for instance, almost all anganwadi workers reported having a “syllabus” for this purpose; some states also provide uniforms for the children.
• Partial findings of the fifth National Family Health Survey (i.e. NFHS-5), carried out in 2019-20 (just before the Covid-19 crisis), point to an alarming stagnation of child nutrition in the preceding four years. The Covid-19 crisis and the economic recession it precipitated in 2020 almost certainly led to a significant worsening of the nutrition situation in the country. In spite of this nutrition crisis, financial allocations for ICDS, maternity benefits, and the Ministry of Women and Child Development as a whole were trimmed in the 2021-22 Union Budget. In real terms, the allocation for ICDS in the Union Budget is about 40 percent lower today than it was seven years ago. India spends less than 0.01 percent of its GDP on PMMVY, and even the authors' estimate of the cost of actual universalisation at NFSA rates (i.e. Rs. 14,000 crore) is less than 0.05 percent of India’s GDP.
• The paper mentions that Tamil Nadu extended maternity benefits to two children and also raised the benefits to Rs. 14,000 per child aside from in-kind support worth Rs. 4,000 in the form of a “maternity nutrition kit”.
Maternity Entitlements in India: Women's Rights Derailed -Jean Drèze, Reetika Khera and Anmol Somanchi, SocArXiv Papers, Second Version, dated 7th April, 2021, please click here and here to access the paper
Video: Full Documentary, Janam Aur Jeevan, Courtesy: Anhad Films, 4th February, 2021, please click here to access
Large Number of Women Do Not Have Access to Maternity Benefits: Survey -Ditsa Bhattacharya, Newsclick.in, 11 April, 2021, please click here to access
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