Does healthcare voucher provision improve utilisation in the continuum of maternal care for poor pregnant women? Experience from Bangladesh

ABSTRACT

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest.

Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care.

Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0–23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.

Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).

Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

KEYWORDS:

• Maternal health
• continuum of care
• poor pregnant women
• antenatal care
• postnatal care
• cluster analysis
• maternal health voucher scheme

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Acknowledgments

Data collection, analysis, interpretation and manuscript writing of this research was funded by the Medical Research Council, UK (MRC) under the MRC-Government of India Department of Biotechnology Newton Fund, grant number MR/N006267/1. The authors acknowledge with gratitude the commitment of MRC. The authors of icddr,b are also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support to icddr,b. We would further like to acknowledge the support of Mizanur Rahman and Morzina Parvin in supervising data collection for the study. The untiring efforts of the project team members are also gratefully acknowledged.

Author contributions

SSM: conception, drafting, finalizing paper, data analysis and interpretation.

MA: data analysis and interpretation, drafting and finalizing paper

SH: drafting manuscript, data collection supervision, critical reviewing manuscript

MNM: data management, analysis, drafting manuscript and reviewing manuscript

SMAH: review data analysis plan, data analysis, critically reviewing manuscript

AHC: data analysis, drafting manuscript and reviewing manuscript

MI: data interpretation, drafting and finalizing paper

WS: conception, drafting, critical reviewing and providing feedback

SP: drafting and critically reviewing manuscript, data analysis

AB: reviewing data analysis plan and data interpretation. Critically reviewing manuscript.

All authors approved the final version of the manuscript.

Data availability statement

The authors confirm that all data underlying the findings in this paper are freely available upon request subject to the adherence to icddr,b’s data sharing policy (http://www.icddrb.org/policies). The request for the data can be sent to [email protected], the Principal Investigator of the project.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

The study was approved by the Ethical Review Committee (ERC) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) (NIH reference# 0000182). Informed written consent was obtained from all respondents, and confidentiality and anonymity of respondents were ensured.

Paper context

Women in developing countries lack access to comprehensive maternal care, a risk factor for high maternal mortality. Continuum-of-care is known as a key programme strategy for reducing maternal deaths. The cluster analysis used in the current paper showed that vouchers encouraged participation in the CoC, particularly for poor women. The analysis identified drop outs in the CoC. Successful interventions to ensure CoC should rely on a better understanding of the gaps in care-seeking along CoC.

Additional information

Funding

This research study was funded by the Medical Research Council, UK (MRC) under the MRC-Government of India Department of Biotechnology Newton Fund, grant number MR/N006267/1.