Abstract
This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.
Highlights
Healthcare interventions delivered in the critical first days after childbirth have the highest potential to prevent maternal and neonatal deaths [1,2,3,4,5]
We find no differences across the phase I and comparison samples in client socioeconomic status; the pool of clients sampled in phase II facilities in 2010 were significantly poorer than the comparison sample (p
Overall quality improvement attributable to the voucher participation appears to be concentrated in care for the mother, with an estimated 86% (FDR q = 0.06) improvement attributed to program participation
Summary
Healthcare interventions delivered in the critical first days after childbirth have the highest potential to prevent maternal and neonatal deaths [1,2,3,4,5]. An estimated 10–27% of the 4 million annual newborn deaths could be averted if effective postnatal care (PNC) were scaled up to 90% coverage globally [1]. PNC coverage remains low in the countries that account for 95% of the global burden of maternal and child mortality, with only one-third of mothers and newborns receiving skilled care in the postnatal period [7,8,9]. Kenya’s progress on coverage of skilled birth attendance and PNC over the past two decades remains relatively low [10,11]. 56% of Kenya’s deliveries continue to occur at home, with only an estimated 1% of these deliveries occurring under the care of skilled birth attendant [12]. In more than 4 out of 5 of these home deliveries, the mother and newborn do not receive any skilled PNC [12]
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