By Diane Coffey and Payal Hathi
The National Food Security Act (NFSA) of 2013 made comprehensive reforms to the Public Distribution System (PDS). A lesser known, but potentially transformative provision of the Act legislates “a maternity benefit of not less than Rs. 6000” be given to “every pregnant and lactating mother.”
In this article, we explain why maternity entitlements are a good investment and think about how they should be designed to have the biggest impact on the health and productivity of the next generation.
It is important to point out that despite the fact that maternity entitlements are written into law, most pregnant women in India do not receive them. With the exception of state-sponsored programmes in Odisha and Tamil Nadu, and a small pilot programme called the Indira Gandhi Matritva Sahyog Yojana (IGMSY), maternity entitlements have not been implemented. An ongoing Supreme Court case and this year’s Economic Survey call attention to the need for maternity entitlements; yet the Centre has not allocated an adequate budget for the programme.
Maternity entitlements are a good investment
In India, neonatal mortality, or death in the first month of life, is far higher than the country’s economic performance would predict. Analysis based on World Bank World Development Indicator data from 181 countries predicts a neonatal mortality rate of 22.4 deaths per 1,000 live births given India’s Gross Domestic Product (GDP) per capita; however, the actual rate in 2013 was 30% higher at 29.2 (Coffey and Hathi 2016). There is also strong evidence that birth weights are anomalously low (Research Institute for Compassionate Economics (r.i.c.e.), 2015). Low birth weight is not only a health issue but also an economic issue: babies who are born small grow up shorter and less cognitively able, and earn less money as adults, as compared with larger babies (Black, Devereux and Salvanes 2007, Behrman and Rosenzweig 2004).
These infant health problems are symptoms of widespread maternal undernutrition. Young women in many Indian households are considered to have low social status. One consequence of this poor social status is that they often work hard and eat little. When pregnant mothers have high energy expenditure and low energy intake, babies are set on a path to a stunted adulthood.
How could maternity entitlements increase birth weight and improve health and productivity?
The evidence is clear that greater caloric intake during pregnancy increases a mother’s weight gain and that greater weight gain during pregnancy results in larger infants.
We should care about increasing birth weights even among those babies who are not less than the cutoff for low birth weight. Doctors and public health professionals use a threshold of 2,500 grams to separate babies into “low birth weight” and “normal birth weight,” but the relationships between weight gain and birth weight, and birth weight and health, are actually continuous. Even above 2,500 grams, heavier infants have better cognitive and health outcomes than lighter ones (Figlio et al. 2013, Adair 2007). This suggests that maternity entitlements can and should be designed to help improve maternal nutrition and pregnancy weight gain for a large fraction of the population.
Maternity entitlements should be designed to improve health
Links in a causal chain
Recent research on programme effectiveness invites policymakers to consider how to get from the programme, in this case, maternity entitlements, to the outcome, healthier children.
In order for maternity entitlements to help improve birth weight and neonatal outcomes, it must reach the pregnant woman’s family in time to improve her pregnancy weight gain; the family must use the money to buy food; the woman must eat the food; and the money must be enough to make a meaningful difference to her diet.
We discuss the links in the causal chain one by one.
The first link in the causal chain from maternity entitlements to better health is that the money must reach the woman while she is still pregnant. Maternity entitlements are currently designed to give women one installment in the last trimester of pregnancy and another installment once the baby is six months old. But study after study (Case and Paxson 2008, Hoddinott et al. 2013), including many that were cited in this year’s Economic Survey, finds that the best time to invest in a child’s future is while h/she is still in the mother’s womb. Earlier investments have higher returns than later ones. Cash, along with education about what to do with it, should be given as a lump sum as early as possible during pregnancy.
The second and third links in the causal chain are that the money must be used to buy food and that the food must be consumed by the pregnant woman. It will be challenging for the government to ensure that these links in the causal chain are strong; where women have little say in household decisions, higher-ranking family members may decide not to spend extra money on pregnant women. This does not mean that it is not worth trying.
The government should make a concerted effort to educate household heads about the importance of investing this additional money in healthy food for pregnant women.
Is Rs. 6,000 enough to make a meaningful difference in a pregnant woman’s diet? Rs. 6,000 may not seem like a lot of money, but deployed properly, it could do a great deal to improve a woman’s diet during the pregnancy. The 2011-12 National Sample Survey (NSS) found that monthly per capita expenditure on food was Rs. 756 in rural areas and Rs. 1,121 in urban areas. An additional Rs. 6,000 invested in the mother’s food would, in principle, let her eat about double what she normally does for eight months in rural India or for more than five months in urban India. Of course, rather than simply increasing the quantity of food that a pregnant woman consumes, the money should also be used to improve the quality of food by adding milk, eggs, fruits, vegetables, and other healthy foods to a diet that lacks them.
Maternity entitlements pilot progamme should be simplified, not merely scaled-up
In September, the Supreme Court issued a notice to the Centre pointing out that the maternity entitlement in the NFSA had not been implemented. The Ministry of Women and Child Development (MWCD) responded by saying that if the Ministry of Finance allocates funds for maternity entitlements, the MWCD would expand IGSMY, the maternity entitlements pilot programme, in its current form.
Merely expanding IGSMY in its current form would be a poor choice. IGSMY is a conditional cash transfer that requires women to jump through a number of bureaucratic hoops before receiving payments. Recipients must register pregnancies with a village health worker, receive antenatal checkups, take iron-folic acid supplements, receive immunisations, attend infant feeding counselling sessions, breastfeed for six months, and begin complementary foods at six months.
While these are indeed important steps for raising healthy children, making them conditions for receiving the entitlement makes little sense. Conditional cash transfers have been successful in Latin America, where public health systems are well-developed. In India, however, major deficiencies in the provision of health services mean that conditional transfers will not work similarly well. Conditional transfers solve demand problems, but India chiefly faces supply problems. Further, those behaviours that are within the mother’s control, such as breastfeeding for six months, are nearly impossible to verify.
Choose a pregnancy-focused design
Some have suggested that distributing the maternity entitlement after the birth of a child could help mothers working in the informal sector better care for a child after birth.
For those young women who work in the paid labour market, this compensation for lost wages could buy time to recuperate at home and to breastfeed, which is extremely important for infant health. These women certainly need more support than they currently receive.
However, we question whether it makes sense to design the NFSA’s universal maternity entitlements around work leave, rather than around a population-wide health issue. The majority of young women in India do not work outside the home: the 2005-06 National Family Health Survey (NFHS) finds that only about a quarter of pregnant women report working outside the home. Most of these women work in agriculture. Although more research and advocacy should certainly be done to figure out how to best address the needs of pregnant women and new mothers who work outside the home, it is not clear that a universal programme should be designed for a relatively special group of women.
If the purpose of maternity entitlements is to improve maternal nutrition and child health, the design of the programme should be a simple one, directed at ensuring healthier pregnancies.
Rather than disburse payments in two separate installments, one of which occurs after the child is born, a single lump sum payment should be made as early in pregnancy as possible, and should be accompanied by education about the importance of rest and weight gain during pregnancy.
Impact of maternity entitlements should be measured
At present, the government does not collect essential health statistics such as weight gain during pregnancy and birth weight. The evidence we have on these problems is available through modeled estimates, which are important, but no substitute for collecting and analyzing survey data.
In this column, we have explained why the government should design and implement maternity entitlements without delay. When they do, it makes sense to accompany this investment with a commitment to measure the impact of the programme. Independent monitoring and sample surveys are crucial for understanding whether maternity entitlements reach beneficiaries and whether or not they improve maternal nutrition and birth weight.
Diane is a demographer and development economist who studies health, nutrition and policy in developing countries, and particularly in India. She is a visiting fellow at the Woodrow Wilson School for Public & International Affairs at Princeton University, a visiting economist at the Indian Statistical Institute, Delhi, and she co-directs a research non-profit called r.i.c.e., a research institute for compassionate economics, which aims to inform policies relating to child health in India.
Payal Hathi is a Managing Director at the RICE Institute, where she does research and policy advocacy on issues related to child and maternal health in India. Prior to r.i.c.e., Payal worked with the World Bank’s Water and Sanitation Program, managing research initiatives in South Asia.
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