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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, geogr...
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Context 1
... show that the predicted probability of non-voucher poor women belonging to the highest utilisation cluster was only 6.8% and the probability for the voucher recipients was higher at 33.3%. On the other hand, the probability of non-voucher poor women being in the lowest utilisation cluster was high at 55.4%, whereas the probability was only 13.3% for the poor women receiving vouchers ( Figure 3). ...
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Background
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Citations
... child health [13]. Evidence from recent years suggests that access to a continuum of care (CoC) during pregnancy, childbirth, and the postnatal period has the potential to yield multiple returns on investments by reducing maternal and neonatal death as well as improving child health outcomes [14,15]. ...
... Provider facilities and individual staff also receive payments for each service provided to the scheme members [18][19][20]. Earlier reports have shown that implementation of the MHVS has substantially increased the utilization of antenatal care, skilled assistance at delivery, and postnatal care services [14]. There is also evidence for improved equity according to socioeconomic status in access to maternal health services, despite some administrative challenges in terms of disbursement of benefits [21][22][23][24]. ...
... Earlier studies have indicated that women using the complete CoC were more likely to experience positive maternal outcomes (e.g. facility-based delivery, skilled birth attendance, PNC use, and so on) [14]. Given the importance of MNCoC, the current study explored the determining factors of MNCoC use among voucher and non-voucher women. ...
Background
Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC).
Methods
A cross-sectional survey was conducted from October’2017 to April’2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing.
Results
Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away.
Conclusion
The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.
... It is one of the most effective ways to reduce mother and child mortality and morbidity [3][4][5]. The World Health Organization (WHO) designated maternal health services, such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) as critical components of the intervention to reduce maternal and child mortality [6,7]. The WHO previously recommended that every pregnant woman undergo at least four (4 +) ANC visits throughout her pregnancy to ensure adequate care [8]. ...
Background
Visiting
the desired number of antenatal care services improve the success of maternal health programs in terms of mother and child health. The study aimed to identify the factors associated with differences in the number of antenatal care service visits across and within regions of Ethiopia by using the 2019 Ethiopian Mini Demographic Health Survey (EMDHS).MethodsA total of 3979 women who were pregnant or gave birth within 5 years preceding the survey from the 2019 Ethiopian Mini Demographic Health Survey were included in the analysis. A multi-level Hurdle negative binomial regression model was selected to consider the hierarchical nature of the data in determining the factors associated with the barriers to the desired number of antenatal care service visits.ResultsAbout one-fourth (26.2%) of mothers did not visit any antenatal care, and only 137 (3.4%) women visited the service eight times and above. The random intercept with the fixed coefficient of multilevel Hurdle negative binomial model results has shown that women in the age group between 25 and 34 (AOR = 1.057), in the age group between 35 and 49 (AOR = 1.108), protestant religion follower women (AOR = 0.918), Muslim women (AOR = 0.945), other religion follower women (AOR = 0.768), mothers in primary educational level (AOR = 1.123), secondary and higher education level (AOR = 1.228), rich mothers (AOR = 1.134), and mothers living in rural (AOR = 0.789) were statistically associated with regional variation regarding the frequency of ANC service visits.Conclusions
The majority of pregnant women did not visit antenatal care services according to the findings of this study. This study’s results revealed that the predictor variables such as mother’s age, education level, religion, place of residence, marital status, and wealth index were significant, and the findings revealed that there were regional differences in ANC visits in Ethiopia. Women’s economic and educational interventions should be a top priority.
... Apart from the direct impact of the voucher scheme on mothers during pregnancy, delivery and postnatal period, there can be some indirect benefits since the concept of safe motherhood has been explicitly linked to disease prevention of children. Literature shows that among other factors such as mother's education; socioeconomic status and age; safe motherhood practices, including antenatal visits, delivery through Skilled Birth Attendant (SBA), institutional delivery and postnatal care are associated with increased immunization coverage (2)(3)(4)(5)(6). ...
... The MHVS is a demand-side financing designed to provide vouchers and cash benefits to disadvantaged pregnant women in Bangladesh to avail services within the scheme, free of cost (2,10). Initially MHVS piloted in 21 sub-districts, and currently operates in 53 of the 556 sub-districts in Bangladesh (3,4). The scheme used universal approach for targeting the nine poorest subdistricts, where all pregnant women of parity 1 or 2 (first or second pregnancy), regardless of poverty status, were offered vouchers. ...
Bangladesh initiated the Maternal Health Voucher Scheme (MHVS) in 2007 to improve maternal and child health practices and bring equity to the mainstream of health systems by reducing financial and institutional barriers. In this study, we investigated whether the MHVS has an association with immunization coverage in a rural area of Bangladesh. Between 30 October 2016 and 15 June 2017, we carried out a cross-sectional survey in two low performing areas in terms of immunization coverage- Chattogram (erstwhile Chittagong division) and Sylhet division of Bangladesh. We calculated the coverage of fully immunized children (FIC) for 1151 children aged 12–23 months of age. We compared the coverage of FIC between children whose mothers enrolled in MHVS and children whose mother did not. We analyzed immunization coverage using crude odds ratio (OR) and adjusted OR (aOR) from binary logistic regression models. The overall coverage of FIC was 86%. Ninety-three percent children whose mothers were MHVS members were fully immunized whereas the percentage was 84% for the children of mothers who were not enrolled in MHVS. Multivariate analysis also shows that FIC coverage was higher for children whose mothers enrolled in MHVS compared to those children whose mothers did not; the aOR was 2.03 (95% confidence interval 1.11–3.71). MHVS provides a window for non-targeted benefits of childhood vaccination. Providing health education to pregnant mothers during prenatal care may motivate them to immunize their children. Programmes targeted for mothers during pregnancy, childbirth and post-natal may further increase utilization of priority health services such as childhood immunization.
... 28 Interventions that mitigate cost of care for elderly women of older age, in sum, may assist in addressing disparities in care at advanced age; such interventions have had demonstrated success in improve access of reproductive healthcare for women. 29,30 In addition, care sought by women is most often with traditional healers (see Figure 1, primary sources). Based on extensive literature on care-seeking behaviors during pregnancy, women may have greater access to traditional medicine than to other sources of healthcare. ...
... 33 The Commission highlighted the importance of the leading three risk factors, from 2013 GBD data, for mortality among women which also constitute leading risk factors for NCDs: diet, high blood pressure, and smoking. 29,33 Unmitigated risk factors can contribute to obesity and gestational diabetes in pregnancy that secondarily can lead to harmful effects on health in their progeny such as increased risk for obesity, cardiovascular disease, and diabetes later in life. 42,43 A case study of gender disparities in chronic respiratory diseases Chronic respiratory disease, which is one of the leading four NCDs, encapsulates the clear gender differences in risks and outcomes discussed previously. ...
... Therefore, opportunities that facilitate women on this topic through education and innovative measures are also necessary. Finally, as tobacco companies continue to target women and girls for marketing, 29,43 strategies need to be pre-emptive in guarding against the rise of tobacco use using effective strategies such as those promoted by the FCTC (marketing campaigns, banning advertising), as well as for the youth such as through games or innovative school-based programs. 125 Align gender-based NCD initiatives with other existing disparity-focused agendas: collaboration over proliferation Finally, in moving forward the NCD agenda overall, it has been noted by many that we are not where we hoped to be post the milestone 2011 UN High-Level meeting -that NCDs have still been left behind. ...
Gender is a social determinant of health, interacting with other factors such as income, education, and housing and affects health care access and health care outcomes. This paper reviews key literature and policies on health disparities and gender disparities within health. It examines noncommunicable disease (NCD) health outcomes through a gender lens and challenges existing prevailing measures of success for NCD outcomes that focus primarily on mortality. Chronic respiratory disease, one of the four leading contributors to NCD mortality, is highlighted as a case study to demonstrate the gender gap. Women have different risk factors and higher morbidity for chronic respiratory disease compared to men but morbidity is shadowed by a penultimate research focus on mortality, which results in less attention to the gap in women’s NCD outcomes. This, in turn, affects how resources, programs, and interventions are implemented. It will likely slow progress in reducing overall NCD burden if we do not address risk factors in an equitable fashion. The article closes with recommendations to address these gender gaps in NCD outcomes. At the policy level, increasing representation and inclusion in global public health leadership, prioritizing NCDs among marginalized populations by global health societies and political organizations, aligning the gendered global NCD agenda with other well‐established movements will each catalyze change for gender‐based disparities in global NCDs specifically. Lastly, incorporating gender‐based indicators and targets in major NCD‐related goals and advancing gender‐based NCD research will strengthen the evidence base for women’s unique NCD risks and health outcomes.
... In the most recent DHS report (2020), 44% of the clusters had a government facility within their village and 9% had a private facility. Individual patients are often charged a small user fee to access public healthcare facilities, while relatively large costs are required to access maternal healthcare services from any private actor (Mahmood et al., 2019;Sarker et al., 2021). In 2016, a total of 43% of women received the complete continuum of maternal care (ANC, childbirth, and postnatal care from medically trained professionals) (NIPORT & ICF, 2019). ...
Floods are a common natural hazard in Bangladesh, and climate change is expected to further increase flooding frequency, magnitude and extent. Pregnant women in flood contexts could face challenges in utilisation of maternal healthcare. The aim of this paper is to analyse associations between flood exposure and the use of maternal healthcare (antenatal care visits, birth assisted by skilled birth attendants, and giving birth in a health facility) in Bangladesh for pregnancies/births between 2004 and 2018. Bangladesh Demographic and Health Survey data from four surveys in the time period 2007–2018 and data on floods from the Emergency Events Database and the Geocoded Disasters Dataset are analysed using multilevel linear probability models. In line with previous results, we find clear bivariate associations between exposure to flooding and maternal healthcare use. These associations are largely confounded by socioeconomic and demographic variables. In general, exposure to flooding — whether measured as exposure to any floods or severe floods — does not affect maternal healthcare use, and we suggest that the lower usage of maternal healthcare in areas exposed to flooding rather relates to the characteristics of the flood-prone areas and their populations, which also relate to lower maternal healthcare use. However, we find negative associations in some supplementary analyses, which suggest that even if there is no effect of floods on average, specific floods may have negative effects on maternal healthcare use.
... Subnational, cross-sectional comparisons of voucher recipients versus nonrecipients, as well as mothers who had recently given birth in upazilas where the program was offered versus not, suggest that the MHVS was associated with greater use of maternal health services and more comprehensive maternal care, with inconsistent evidence on out-of-pocket expenditures [18,20,[24][25][26][27]. However, this research cannot inform inference regarding the causal effect of the MHVS. ...
... Our analyses support 2 main conclusions. First, the introduction of the MHVS was positively associated with selected maternal health services, particularly the probability of delivering in a health facility, which is consistent with the literature on the impact of voucher schemes in LMICs [33], including Bangladesh [20,23,24,27,28]. Second, despite having a longer period of follow-up than most extant evaluations [31,33], we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. ...
... Second, despite having a longer period of follow-up than most extant evaluations [31,33], we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Our results cohere with the few empirical studies that have examined impacts of voucher programs on measures of utilization and health outcomes [33], with prior research indicating that access to the MHVS was associated with greater use of maternal health services, including antenatal care, having a skilled attendant at delivery, delivering in a health facility, receiving postnatal care, and more comprehensive maternal care [20,24,25,27]. One cross-sectional study comparing voucher recipients to nonrecipients suggested that recipients were more likely to seek medical assistance in case of obstetric complications [54]. ...
Background:
Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.
Methods and findings:
We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.
Conclusions:
In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.
... A major challenge to policy makers has been to find ways to promote access to maternal services by removing barriers in uptake of these services especially among the poor, and ensure that public subsidies are better targeted to those who need them most [11]. Both these concerns are addressed by demand side financing approaches and therefore, many countries have been experimenting with strategies like conditional cash transfers and use of vouchers to improve access to health services in general and maternal health services in particular [12][13][14][15][16][17][18][19][20] . ...
... Generally with RBF, improvements have been observed in service utilization but impact on quality has been harder to demonstrate. A recent analysis of the Bangladesh Maternal Health Voucher Scheme indicates a positive impact on access to services especially for marginalized women and on the completeness of antenatal care [29,30]. Such impact might be expected to feed through to a reduction in stillbirth risk but evidence for this remains elusive to date. ...
Background
Malawi implemented a Results Based Financing (RBF) model for Maternal and Newborn Health, “RBF4MNH” at public hospitals in four Districts, with the aim of improving health outcomes. We used this context to seek evidence for the impact of this intervention on rates of antepartum and intrapartum stillbirth, taking women’s risk factors into account.
Methods
We used maternity unit delivery registers at hospitals in four districts of Malawi to obtain information about stillbirths. We purposively selected two districts hosting the RBF4MNH intervention and two non-intervention districts for comparison. Data were extracted from the maternity registers and used to develop logistic regression models for variables associated with fresh and macerated stillbirth.
Results
We identified 67 stillbirths among 2772 deliveries representing 24.1 per 1000 live births of which 52% ( n = 35) were fresh (intrapartum) stillbirths and 48% ( n = 32) were macerated (antepartum) losses. Adjusted odds ratios (aOR) for fresh and macerated stillbirth at RBF versus non-RBF sites were 2.67 (95%CI 1.24 to 5.57, P = 0.01) and 7.27 (95%CI 2.74 to 19.25 P < 0.001) respectively. Among the risk factors examined, gestational age at delivery was significantly associated with increased odds of stillbirth.
Conclusion
The study did not identify a positive impact of this RBF model on the risk of fresh or macerated stillbirth. Within the scientific limitations of this non-randomised study using routinely collected health service data, the findings point to a need for rigorously designed and tested interventions to strengthen service delivery with a focus on the elements needed to ensure quality of intrapartum care, in order to reduce the burden of stillbirths.
... A major challenge to policy makers has been to find ways to promote access to maternal services by removing barriers in uptake of these services especially among the poor, and ensure that public subsidies are better targeted to those who need them most [11]. Both these concerns are addressed by demand side financing approaches and therefore, many countries have been experimenting with strategies like conditional cash transfers and use of vouchers to improve access to health services in general and maternal health services in particular [12][13][14][15][16][17][18][19][20] . ...
Background
Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997–2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India.
Methods
This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015–16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India.
Results
On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors.
Conclusions
The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India’s impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.
... The adoption and scaling-up of demand-side financing (DSF) models has become popular among policymakers in less-developed countries as an instrument to improve access to maternal and child health services. Studies from different countries confirm higher utilization of health care services as a result of DSF (Bhatia et al., 2006;Bhatia & Gorter, 2007;Anwar et al., 2008;Mahmood et al., 2019). This study evaluated the effect of a voucher scheme programme as a tool of DSF on access to, and utilization of, antenatal care with special emphasis on completeness of access to different components of care considered medically necessary and useful. ...
This study aimed to assess completeness of antenatal care coverage following implementation of a voucher scheme for maternal health in Bangladesh. The investigation used interview data from a survey conducted in Bangladesh in 2017 of 2400 randomly selected women aged 15–49 with children aged 0–23 months in four geographical areas where voucher scheme implementation was underway. Of these women, 1944 had attended at least one antenatal clinic visit so were included in the analysis. A ‘completeness index’ for antenatal visits was constructed as an outcome variable based on recall of thirteen elements of care. Bivariate analysis against independent variables of interest was carried out and multivariate linear regression models developed to examine the influence of voucher scheme participation on completeness of antenatal care adjusting for socio-demographic characteristics. Voucher scheme membership was associated with higher ‘completeness index’ scores, with a mean score of 185.2±101.0 for voucher recipients and 139.6 ± 93.3 for non-recipients (p<0.001). Scheme membership reduced the differentials associated with health facility type and socioeconomic status. Women from the lowest socioeconomic group who were voucher recipients received substantially more components of antenatal care (mean score: 159.6±82.1) compared with non-recipients (mean score: 115.7±83.0). This favourable effect of voucher scheme membership on the most vulnerable socioeconomic group remained significant after adjusting for educational status. The Bangladesh voucher scheme model has the potential to maximize gains in maternal and newborn health through enhancing the completeness of service provision.
