Most of the time, babies arrive without complications—at least 85 percent of all births occur without a serious problem.source But when complications do arise they can be fatal, threatening both mother and infant. Most maternal death occurs during labor, delivery, or immediately after delivery.source

Across India, maternal and infant mortality rates have varied significantly by socioeconomic status and by state. In Gujarat, a state in northwest India, the rate of loss of mothers and babies during childbirth was unacceptably high, in part because only 55 percent of births took place in a medical facility as of 2005. This was in sharp contrast to Kerala, in southwest India, where coverage of facility births had reached 99 percent.source

In 2005, Gujarat’s government designed and introduced a new scheme to improve birth outcomes, called Chiranjeevi Yojana (CY) or the “Eternal Life” scheme. It aimed to tackle the state’s low rate of institutional delivery by removing one of the most important barriers for women with the highest risk of maternal mortality: the cost of the service. This was done primarily by incentivizing the private sector to serve below-the-poverty-line (BPL) and tribal women.

The scheme held great promise. CY was built on a strong foundation of international good practice, a vibrant private sector, and political commitment by the state’s leadership. And many families benefited from CY. By 2012, the pool of roughly 800 enrolled obstetricians had delivered 800,000 babies in health facilities, including a third of all births to BPL and tribal women.source

The CY experience serves as a cautionary tale for programs that seek to improve maternal and infant health by increasing institutional delivery

Despite these impressive numbers, however, independent evaluations of CY found that the scheme did not significantly increase the likelihood of institutional delivery and did not reduce maternal or infant deaths.source This is partly explained by changes in India’s overall health landscape: rates of institutional delivery were already rapidly increasing, and indicators of maternal and infant health were on the rise. These underlying trends reduced the relative impact of CY’s contribution. In addition, some of the features of CY’s design, such as a disincentive for unnecessary caesarian sections, turned out to be less valuable than its planners expected.

Improving maternal and infant health is a global health priority for which funding is at an all-time high.source Gujarat’s experience reveals the importance of carefully considering many different components of program design, including financing, monitoring, entry criteria, and quality assurance, alongside the social determinants of health.