Mumbai: “We spent around Rs 10,000 on my pregnancy, including travelling costs,” Rubeena Sheikh said, with a quick glance at her mother-in-law, a movement she makes at the end of every answer.

Four days earlier, Rubeena had given birth to her second child, and she was waiting for the Rs 6,000 allowance under the Pradhan Mantri Matru Vandana Yojana (PMMVY), a maternity support scheme by the Union government aimed at promoting healthy behaviour practices among pregnant women. Even though the scheme was introduced seven years ago, experts reveal turbulence in uptake and implementation of the scheme, and raise concerns over its budgetary allocation.

The Pradhan Mantri Matru Vandana Yojana was initiated in 2017 as per provisions under the National Food Safety Act, 2013, and provides financial support of Rs 5,000 for pregnant women and lactating mothers during the first pregnancy, as compensation for partial wage loss, and to improve the wellbeing and health-seeking behaviour of the mother and child.

In 2022, the scheme was updated and added to an overarching women empowerment scheme called Mission Shakti by the Ministry of Women and Child Development. The revised scheme, referred to as PMMVY 2.0, sought to discourage female foeticide and offered an allowance of Rs 6,000 to a second child, if the infant is a girl.

Agency and awareness

Rubeena’s home in Rafeeq Nagar, Mumbai was one among the 40,000 homes with joint families crammed into one-room houses. With the closest accessible hospital over 6 km away, she spoke of the hardships of getting tests and paperwork done for availing the scheme.

To apply for the scheme, women are required to produce their bank account details, government identification cards including Aadhaar and ration cards along with registration details of their mother and child protection card (MCP), which records the date of pregnancy as the date of their last period.

“Most women don’t have their ration cards updated with their husband’s family details or have a registered bank account,” said Sabrin Sheikh, a staff member from Apnalaya, a non-profit that works to increase awareness of government schemes in impoverished areas. “Getting these done takes a lot of time as they are not allowed to travel unless accompanied by their husband or mother-in-law. The husbands are mostly informal sector workers who often don’t have time to go after these things.”

For each instalment to come through, a set of conditions have to be met, including conducting antenatal checkups and registering the pregnancy and getting immunisation shots, in the case of the last instalment. “Mostly, they deliver the baby by the time these records are obtained,” Sheikh added.

Scheme Conditions of Pradhan Mantri Matru Vandana Yojana

Women in rural households, especially with low levels of education, experience a significant lack of agency. In rural India, only 46% of women own property alone or with others, while 46% have a mobile phone that they themselves used, according to the National Health Survey, 2019-21 (NFHS-5). The expectation that girls should conform to social and family expectations and refrain from independent action structures their lives and thoughts, the ASER 2023 report points out.

Cultural traditions and beliefs also add to the means of restriction of women. “In many cases, the choice does not lie with the mother. There is a stigma around revealing pregnancy in the first trimester, which is believed to attract the ‘evil eye’. If you really look at it, the problem boils down to lack of awareness and change of mindset,” said Rama Nath, Project Director at Society for Nutrition, Education and Health Action.

Only 54% of pregnant women from rural areas had at least four antenatal visits and 67% had an antenatal checkup in the first trimester, according to NFHS-5. Antenatal care can reduce health risks for mothers and babies as it includes monitoring pregnancies and screening for complications.

Proactive registration of pregnancy and general awareness about health and wellbeing during pregnancy is the need of the hour, experts say. Women need to take the initiative and access the services available to them, but the other side of the coin is the quality of the service offered.

Crippling lack of services

Adequate maternal care and rest is essential for intrauterine growth and can affect the baby’s birth weight. UNICEF reported in 2018 that India has the highest number of malnourished children in the world, with an estimated 46.6 million children under the age of five suffering from stunting. Due to economic and social difficulties, many women in impoverished India continue to toil away at work till they give birth.

About 1.3 million maternal deaths occurred between 1997 and 2020, with about 23,800 in 2020. Most maternal deaths occur in the poorer states (63%) and among women aged 20-29 years, according to a study published in the National Library of Medicine. Most mothers end up going back to work sooner than they should, which in turn causes harmful consequences for both the mother and the baby.

“Our country is large but the infrastructure per capita is miniscule,” said Dileep Mavlankar, professor and director of Indian Institute of Public Health. “Our public health system has not improved despite the pandemic. Normally, the nurse to patient ratio is 4:1 but in our public health centres, we have even 100:1. The public health centres in rural areas have only one auxiliary nurse, not even a fully qualified one. We need to improve emergency auxiliary care and appoint skilled midwives. We need to invest in health education so that people can become better educated about their own health.”

Read more about India’s healthcare system here in IndiaSpend article, Why Adding Medical Colleges Isn’t Enough To Improve India’s Healthcare

Changes and delays

Apart from the general lack of awareness about government schemes, people are discouraged from applying or accessing the schemes due to changes in guidelines and taking the effort to avail them by procuring all the required documents.

“When there are revisions in schemes, people who are unaware are turned away,” said Rama Nath. “This is very discouraging and makes people think the scheme or the portal is just not working.”

Over the past two decades, the Union government scheme offering maternal services has changed names and norms four times. It began as the Indira Gandhi Matritva Sahyog Yojana, launched in October 2010 to provide cash incentives of Rs 4,000 in three instalments for improving health and nutrition status of pregnant women.

When the National Democratic Alliance government under PM Narendra Modi took office, the scheme was renamed to Pradhan Mantri Matritva Vandana Yojana, and then again to PMMVY.

In 2022, as we said, PMMVY was clubbed within an overarching women empowerment scheme called Mission Shakti.

“The continuous change of names causes confusion, hinders trust building and brand building. We need to focus on providing the basics instead of all this show,” said Mavlankar.

Differences between PMMVY and PMMVY 2.0

There was a 7% increase in beneficiaries registered under PMMVY from 2020 to 2021, but by November 2022, the number of beneficiaries fell by 46% compared to the same period in the previous year, according to a budget brief by the Accountability Initiative. This decline could be because of the new guidelines that state that benefits can be availed only on the basis of the Aadhar numbers of eligible citizens, the brief stated.

The only aspect that remains the same is the compensation for the first live birth. It does not account for inflation and has remained the same since 2017. Adjusted for inflation, at the national level, compensation should have increased by at least Rs 1,599 to Rs 6,599, the Initiative points out.

Stalling instalments and decreasing budgets

Maternity benefits of Rs 14,427 crore have been disbursed to over 32.1 million beneficiaries as of February 19, 2024, the PMMVY dashboard shows. It is unclear how many women received both instalments under the scheme. For instance, only 29% of eligible citizens who had been paid had received all their instalments until November 2022, according to the Accountability Initiative.

The scheme, as we said, is intended to make up for partial wage loss for pregnant women. The minimum wage prescribed by the government for unskilled workers is Rs 12,270 per month. The compensation provided under the scheme thus does not meet the financial requirements of pregnant women, forcing them to continue unhealthy working practices during the time of pregnancy. And yet, the budget allocated for the scheme in 2023-24 decreased 17% to Rs 2,067 crore from the amount allocated in 2020-21.

The decrease in budget is in tune with the overall lack of emphasis on quality healthcare in the country. “India has a gross under investment in public health systems,” said Mavlankar. “We are a population surplus country and our leaders need to acknowledge that medical and public health is a huge part of that infrastructure. We have a disproportionate emphasis on infrastructure. Modernity means even rural people having access to quality healthcare.”

From 6,000 beneficiaries referred to the PMMVY between January and December 2023 in a few parts of Mumbai, only 1,500 were taken up, according to data from the Society for Nutrition, Education and Health Action (SNEHA).

In its analysis for Budget 2023-24, Accountability Initiative estimated that there were 19.8 million pregnant women and lactating mothers in 2022, over 16.1 million more than the enrolled eligible citizens in 2022-23. Consequently, the estimated cost for the first live birth under the scheme alone was three-fold higher than the allocations for 2022-23, the analysis showed. The estimated cost of second live birth payment results in an additional cost of Rs 2.05 crore. This suggests that the existing allocations did not even cover for the first live birth in 2021-22, the analysis said.

Source: Accountability Initiative analysis based on Union Budget

“We have demand, but we are still cutting down on supply. This decrease in allocation is concerning, considering we have a large marginalised population. The Public Health department has been supportive, especially in working with civil society organisations but the gap between the referral and uptake requires a scientific analysis,” said Rama Nath of SNEHA.

The latest update for the scheme was the launch of an online portal, PMMVYsoft MIS, in 2023 through which beneficiaries are paid via direct account transfers. This change is intended to make it easier for departments to manage data about beneficiaries, but only 46.6% of women in rural India are connected to the internet.

Experts urge the need of adequate evaluation of the schemes that are currently in place. Mavlankar argues, “We are not recording maternal mortality appropriately, we are not appointing statisticians. Evaluation of maternal child health programmes is simply not done.”

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