The Chiranjeevi Yojana programme in Gujarat, India, promotes institutional childbirth among poor and tribal women. The retrospective evaluation of the programme, by Mohanan et al., has some limitations.¹Mohanan M, Bauhoff S, La Forgia G, Babiarz KS, Singh K, Miller G. Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis. Bull World Health Organ. 2014 Mar 1;92(3):187-94.http://dx.doi.org/10.2471/BLT.13.124644 pmid: 24700978
http://dx.doi.org/10.2471/BLT.13.124644...

The five early implementing districts are socioeconomically and demographically different from the 21 later implementing districts,²Cowlagi committee. Districtwise list of 25 most backward talukas of Gujarat. Report of the committee to study backwardness of talukas of Gujarat. Gandhinagar: Government of Gujarat; 2005. p. 17. leading to unmeasured confounding. Also, the wide confidence intervals in table 2 are of concern, as they suggest that the sample of births in each district may have been too small to adequately assess variability at the district level. The authors do not report the overall or annual number of births per district. If we assume that there was one birth per surveyed household and that these births were evenly distributed over each of the five years, we would estimate an average of 250 births over five years or 50 births per year, per district. This may explain the wide confidence intervals and large standard deviations reported. An average sample of 50 births per year in each district may be inadequate to capture the variability both within and between districts and could potentially lead to biased conclusions.

As the sample consisted of households with a poverty score ranging from 16 to 25, the sampling method excluded the poorest households (those scores less than 16), the group that would be most likely to benefit from the Chiranjeevi Yojanaprogramme. In 2012, about 17% of the population lived below the poverty line in Gujarat.³Key data on rural development from IDFC India rural development report. Social development table 7.2: State-wise proportion of population below poverty line (Rural/Urban/Rural+Urban) (Per Cent) (2004, 2009-10 and 2011-12). New Delhi: Indian Ministry of Rural Development; 2015. Available from:http://rural.nic.in/netrural/rural/sites/IDFC.aspx.
http://rural.nic.in/netrural/rural/sites... Also, a higher proportion of impoverished households exist in the early implementing districts than in the 21 comparison districts. Systematically excluding these households would also introduce a bias.

The use of self-reports for obstetric complications may also lead to bias.⁴Sloan NL, Amoaful E, Arthur P, Winikoff B, Adjei S. Validity of women's self-reported obstetric complications in rural Ghana. J Health Popul Nutr. 2001 Jun;19(2):45-51. pmid: 11503346 ⁵Ronsmans C, Achadi E, Cohen S, Zazri A. Women's recall of obstetric complications in south Kalimantan, Indonesia. Stud Fam Plann. 1997 Sep;28(3):203-14. http://dx.doi.org/10.2307/2137888 pmid: 9322336
http://dx.doi.org/10.2307/2137888... The study design is based on differences occurring over short time periods: in the year between the start of the programme in the early and late implementing districts. However, Chiranjeevi Yojana was still establishing itself in those districts. Data on deliveries under the Chiranjeevi Yojana programme in Gujarat indicate that these climbed steadily for the first two to three years following implementation.⁶De Costa A, Vora KS, Ryan K, Sankara Raman P, Santacatterina M, Mavalankar D. The state-led large scale public private partnership 'Chiranjeevi Program' to increase access to institutional delivery among poor women in Gujarat, India: How has it done? What can we learn? PLoS ONE. 2014;9(5):e95704. http://dx.doi.org/10.1371/journal.pone.0095704pmid:24787692
http://dx.doi.org/10.1371/journal.pone.0... As the authors write, overall institutional delivery has increased in Gujarat since the Chiranjeevi Yojana programme was implemented. Government statistics indicate a rise from 50% to 90% between 2005 and 2010.⁷Department of Health and Family Welfare. Annual administrative report 2012-13.; Gandhinagar: Government of Gujarat 2013. Available fromhttp://gujhealth.gov.in/images/pdf/AAR12-13.pdf.
http://gujhealth.gov.in/images/pdf/AAR12... ⁸Department of Health and Family Welfare. Annual administrative report 2005-06.; Gandhinagar: Government of Gujarat 2006. Much of this rise is attributable to an increase in private sector deliveries. We are concerned that the large secular increase in the proportion of institutional deliveries might obscure an even larger proportional increase in institutional deliveries among the poor. This is because the programme specifically targets households below the state-specific poverty-line (of 15) which represented 23% of the population in Gujarat in 2010.⁹Planning Commission of India. Press note on poverty estimates 2009-10. New Delhi: Government of India; 2012. Available from:http://planningcommission.nic.in/news/press_pov1903.pdf.
http://planningcommission.nic.in/news/pr... The increase among the poor might be difficult to detect in the small samples examined in this study. It is also unclear why the authors chose the entire District Level Household Survey-3 sample of women who gave birth after 2005 and not just the population targeted by the programme. Perhaps this was due to difficulties in obtaining a sufficient sample size of women in this stratum, but this broad inclusion could substantially bias results.

For these reasons, we suspect that the authors' samples and methods may have led to a type II error - i.e. the real effect was disregarded.

Many programmes are scaled up by governments before evidence is generated of their effectiveness. If evaluation is omitted before scaling up, a relevant well-functioning health management information system will allow some estimation of the programme's impact. The impact can be estimated by comparing selected indicators in the target group before and after the programme is implemented. For the Chiranjeevi Yojana programme, obtaining relevant indicators from the health information system would have been problematic because maternal deaths are rare events that tend to be underreported

Our recent assessment⁶De Costa A, Vora KS, Ryan K, Sankara Raman P, Santacatterina M, Mavalankar D. The state-led large scale public private partnership 'Chiranjeevi Program' to increase access to institutional delivery among poor women in Gujarat, India: How has it done? What can we learn? PLoS ONE. 2014;9(5):e95704. http://dx.doi.org/10.1371/journal.pone.0095704pmid:24787692
http://dx.doi.org/10.1371/journal.pone.0... based on secondary data obtained from the Department of Health and Family Welfare, Gujarat, India, indicates that approximately a third of all institutional deliveries in the target group occurred under the Chiranjeevi Yojana programme. However, the variations between districts were large. Despite covering nearly a million deliveries, Chiranjeevi Yojana could still increase its coverage of eligible beneficiaries. It would be useful to investigate where the greater proportion of eligible women deliver and what barriers they face to entering the programme. Our assessment indicates that between 2006 and 2010, 6% of deliveries provided by Chiranjeevi Yojanawere caesareans.(6) This is higher than before the implementation of the programme, when 2% of women in the two lowest wealth quintiles reported a caesarean delivery in the DLHS survey.¹⁰District Level Household and Facility Survey (DLHS-3), 2007-08: India. Mumbai: International Institute for Population Sciences; 2010. We cannot assess if deliveries have shifted from home, government facilities or paying private facilities to the Chiranjeevi Yojana programme, as these data were not recorded. Nevertheless, from the women's perspective, delivery under the programme is likely to represent a shift to safe delivery facilities where functional emergency obstetric care is available at lower cost.

Acknowledgements

Ayesha de Costa is also affiliated with the Indian Institute of Public Health, Ahmedabad, India.

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