Date Published: May 9, 2019
Publisher: Public Library of Science
Author(s): Anita Makins, Jochen Ehmer, Alexandra Piprek, Francisco Mbofana, Amanda Ross, Michael André Hobbins, Eileen Stillwaggon.
The Maternal Mortality Ratio in Mozambique has stagnated at 405 deaths per 100,000 live births with virtually no progress over the last 15 years. Low Institutional Birth Rates (IBRs) levelling around 50% in many rural areas constitute one of the contributing reasons. Demand-side financing has successfully increased usage of maternal health services in other countries, but little information exists on in-kind incentives in rural Africa. The objective was to test the impact on Institutional Birth Rates of giving a USD 5.50 baby package incentive to every woman who came to give birth in a health centre in a rural, poor district of Cabo Delgado, Mozambique.
The intervention was implemented in one district in 2010 with the remaining 15 districts serving as controls. The total population in the 16 districts in 2006 was just under 1.5 million people. IBRs were observed from 2006 to 2013 (53 months before and 55 months after the intervention began). The non-intervention districts showed a slight increase, from a mean IBR of 0.39 (SD = 0.10) in 2006 to 0.67 (SD = 0.13) in 2014. The intervention district had a dramatic increase in IBRs within six months of the start of the intervention in 2010, which was sustained until the end of the study. Adjusting for the background increase and for confounders, including health facilities and health personnel per district, and taking clustering in districts into account, the estimated rate ratio of institutional births in the intervention district was 1.80 (95% CI 1.72, 1.89 p<0.001). Women were almost twice as likely to have an institutional birth following the introduction of the baby package.
Pregnancy and birth are critical periods in life. Globally, every year, one million babies die from complications during childbirth. An additional two million are stillborn due to problems arising during the last trimester of pregnancy . Twenty million women suffer from pregnancy-related illnesses . Every minute at least one woman dies from complications related to pregnancy or childbirth . A large proportion of maternal and neonatal morbidity and mortality is preventable. Evidence-based, effective interventions to reduce pregnancy-related morbidity and mortality are well known and documented . Resource-rich countries have implemented several interventions with success, and several resource-poor countries have undertaken fruitful efforts to scale them up, as was the case in Nepal . Other countries have made less progress, especially in Sub-Saharan Africa [6,7]. As a result, more than 95% of maternal , neonatal  deaths and stillbirths  occur in low-income and middle-income countries. Inequalities also exist within countries; poor mothers in poor countries have less access to health care than wealthy mothers in poor countries . Facility-based intrapartum care in the presence of a skilled birth attendant has been demonstrated to be a key strategy to reduce morbidity and mortality . This paper focuses on increasing institutional birth rates as a strategy to improve maternal morbidity and mortality rates, although it is unable to document this as an outcome.
In the observation period comprising 53 months before and 55 months after the start of the intervention, 634,529 births were expected to take place in the 16 study districts (7.3% in the intervention district and 92.7% in the comparison districts). These include both home and institutional births. A total of 375,850 institutional deliveries were recorded. In 2006, the institutional delivery rate in the intervention district of Ancuabe was 0.34 institutional births per expected birth compared to 0.39 (SD = 0.10) in the 15 rural non-intervention districts. Over time, the institutional delivery rates for the non-intervention districts show a moderate increase from the mean rate of 0.39 to 0.67 (SD = 0.13), with variation among the districts (Fig 1 and S1 Table).
This study suggests that demand-side financing in form of a USD 5.50 baby package was a sufficient pull factor in the rural district of Ancuabe to double institutional birth rates and sustain them at that level. The importance of this finding lies in the known clinical benefits of an institutional birth compared to a home birth in the rural African context. In low resource settings, home birth is a hazardous affair both for the mother and the neonate. The importance of access to health services during the ‘golden 24 hours’ surrounding birth are well understood  as are the health benefits of avoiding unhygienic birth conditions and poor practices common in rural home births. The baby package in rural Ancuabe seemed to resolve steps 1 and 2 in Thaddeus and Maine’s description of the barriers faced by pregnant women in accessing appropriate health care . In addition, institutional birth links women to other beneficial services such as breast-feeding counselling, family planning, prevention of vertical HIV transmission, timely neonatal care in the event of complications and vaccination. Institutional births are thought to reduce neonatal mortality by 29% . The results are clear-cut and are also consistent with previous findings in Zambia .