Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya.

Mardieh L Dennis,Ben Bellows,Timothy Abuya,Oona M R Campbell,Matteo Quartagno,Lenka Benova

doi:10.1093/heapol/czz004

Abstract

This study explores the relationship between two health financing initiatives on women’s progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006–16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women’s timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.

Highlights

From 1990 to 2015, the global maternal mortality ratio (MMR) decreased by 44% from an estimated 385 to 216 maternal deaths per 100 000 live births (Alkema et al, 2016)
Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation, (2) receiving continuous care (1þ ANC, facility birth, 1þ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4þ ANC, facility birth, 1þ PNC, with first check occurring within 48 h of delivery)
The odds of starting ANC within the first trimester were 44% lower [adjusted odds ratio 1⁄4 0.56; 95% confidence interval (CI): 0.43–0.73] among births to mothers with four or more children and 25% lower among births to mothers with two to three children compared with women pregnant with their first births

Summary

Introduction

From 1990 to 2015, the global maternal mortality ratio (MMR) decreased by 44% from an estimated 385 to 216 maternal deaths per 100 000 live births (Alkema et al, 2016). The effects of maternal health financing strategies globally and in Kenya have been assessed by examining use of care at individual points along the maternal health continuum While many of these studies suggest that vouchers, health insurance, and reducing or eliminating user fees increase coverage of ANC, facility delivery and PNC individually, there has been no focus on how such financing mechanisms affect continuity of maternal care as measured from the perspective of women’s pathways from pregnancy to the post-partum period (Bellows et al, 2011; Brody et al, 2013; Comfort et al, 2013; Dzakpasu et al, 2014; Gopalan et al, 2014; Wang et al, 2016; Hunter et al, 2017)

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