The Influence of Cash Transfer Program on Institutional Delivery in Nepal

Background and Purpose: Each year 130 million children are born worldwide of which approximately four million experience neonatal deaths or deaths within the first four weeks of life. Over 80% of neonatal deaths are associated with three causes: pre-term births, infections and asphyxia. These deaths could be avoided if births took place in an institutional setting where birth attendants are adequately informed to attend pregnant women and newborn babies with complications. In South Asia, however, women have traditionally given births at home and many continue to do so. Nearly 60% of women in Nepal and 52% in India continue to choose the home delivery option over an institutional delivery that lowers the risk of maternal and child mortality.

Conditional Cash Transfer (CCT) programs, demand side programs, to improve health and education began in Latin America starting with Mexico’s national program, PROGRESSA in 1997. Evaluation of these CCT programs provides evidence of positive impact on the use of health services, nutritional status, health, and educational outcomes of children in these countries. As a result, more countries in Africa and Asia are inspired to adopt their own version of cash incentives. To increase demand for institutional delivery South Asian countries have introduced various forms of CCT schemes that offer women up to $30 in cash if they come to deliver at a health facility. In 2005, Nepal introduced its Safe Delivery Incentive Programme (SDIP)--a cash incentive program nationwide-- to boost the rate of institutional delivery and care from health professionals at childbirth. This study examined if Nepal’s SDIP increased institutional delivery.  

 Methods: We analyzed 2011 Nepal Demographic and Health Survey (NDHS) data, nationally representative data that interviewed 12,674 women between 15 and 49 years of age, of which 4,019 had given birth in the past five years. Using multiple logistic regression analysis, we predicted if the cash incentive program increased the odds of institutional delivery controlling for sociodemographic and geographic factors. 

 Results: Approximately 42% of the women had delivered their youngest child at an institution in 2011. Of the total sample that delivered at a health facility, 65% received cash incentive and the remaining 35% did not receive any cash incentive. The predicted odds of institutional delivery increased by two fold in districts where at least 15% of the new mothers had received cash assistance compared to the districts where less than 15% had received the cash assistance. Other factors that positively correlated with institutional delivery included women’s education, wealth, urban status, and their recommended number of antenatal visits.

Conclusion and Implications: The SDIP has increased institutional delivery in Nepal and this program is worth scaling. Social workers and health care professionals should focus on strengthening outreach programs to increase women’s awareness about the cash incentive program. Additionally, they should work to increase young girls’ access to high school education and pregnant women’s access and use of antenatal care.