Community boat service to promote institutional delivery in the Philippines: a mixed-methods study of a social innovation

Abstract

BackgroundRemote islands have limited access to institutional obstetric care, and these challenges are further exacerbated by climatic threats. A Health Service Boat Project was implemented in rural Philippines to provide free boats for pregnant people to deliver at facilities and facilitate prenatal outreach.ObjectiveTo evaluate the impact of the boat project on institutional delivery rates and to explore the underlying mechanism.MethodsA sequential mixed-methods study was conducted in Zumarraga Municipality, Philippines. In the quantitative component, we analysed the data from nationally representative household surveys and governmental data to assess the institutional delivery rate before and after the boat project started in 2012. Linear difference-in-difference regression analysis was used to test the intervention effects of the boat project on institutional delivery. Weather information obtained from the Philippine Atmospheric, Geophysical and Astronomical Services Administration was used to compare the institutional delivery rate between cyclone-affected and non-cyclone-affected periods. In the qualitative component, we conducted two focus group discussions and two semistructured interviews to explore how the boat service may have improved the institutional delivery rate.ResultsThe institutional delivery rate significantly increased the year after the boat project started (B=0.38, p<0.001). The median institutional delivery rate during the cyclone-affected period was significantly lower than that during the non-cyclone-affected period but still remained high at 93.3%. Pregnant women who used the boat service to facilitate institutional delivery reported that they trusted the service, which was available regardless of economic status and political affiliations. The boat project also allowed community health workers to conduct more frequent prenatal check-ups in the community, leading to an improved rapport between health workers and women. The main challenge identified during the implementation was the limited budget for long-term maintenance of the boat.ConclusionThe boat project not only facilitated transportation for pregnant people to the facility but also improved community-based prenatal services. In addition, the boat project may mitigate some of the effects of cyclones on access to health services for pregnant people.