Impact evaluation of the free maternal healthcare policy on the risk of neonatal and infant deaths in four sub-Saharan African countries: a quasi-experimental design with propensity score Kernel matching and difference in differences analysis

Abstract

ObjectiveDespite the huge financial investment in the free maternal healthcare policy (FMHCP) by the Governments of Ghana and Burkina Faso, no study has quantified the impact of FMHCP on the relative reduction in neonatal and infant mortality rates using a more rigorous matching procedure with the difference in differences (DID) analysis. This study used several rounds of publicly available population-based complex survey data to determine the impact of FMHCP on neonatal and infant mortality rates in these two countries.DesignA quasi-experimental study to evaluate the FMHCP implemented in Burkina Faso and Ghana between 2007 and 2014.SettingDemographic and health surveys and maternal health surveys conducted between 2000 and 2014 in Ghana, Burkina Faso, Nigeria and Zambia.ParticipantsChildren born 5 years preceding the survey in Ghana, Burkina Faso, Nigeria and Zambia.Primary outcome measuresNeonatal and infant mortality rates.ResultsThe Propensity Score Kernel Matching coupled with DID analysis with modified Poisson showed that the FMHCP was associated with a 45% reduction in the risk of neonatal mortality rate in Ghana and Burkina Faso compared with Nigeria and Zambia (adjusted relative risk (aRR)=0.55, 95% CI: 0.40 to 0.76, p<0.001). In addition, infant mortality rate has reduced significantly in both Ghana and Burkina Faso by approximately 54% after full implementation of FMHCP compared with Nigeria and Zambia (aRR=0.46, 95% CI: 0.36 to 0.59, p<0.001).ConclusionThe FMHCP had a significant impact and still remains relevant in achieving Sustainable Development Goal 3 and could provide lessons for other sub-Saharan countries in the design and implementation of a similar policy.

The impact of health sector‐wide approaches on aid effectiveness and infant mortality

“…To place this in context, recent quasi‐experimental evidence comparing Ghana and Burkina Faso against Nigeria and Zambia (Dwomoh et al, 2020) suggests that free maternal healthcare can cut the risk of infant mortality by more than half (RR = 0.46, 95%CI: 0.36 to 0.59). A recent randomised trial conducted in five districts of India reported smaller but still large magnitude reductions in odds of infant mortality (OR = 0.67, 95%CI: 0.54 to 0.83) for home‐based newborn care delivered by dedicated health workers (Rasaily et al, 2020).…”

Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study

“…Clustering and stratification will be adjusted for using sample survey weighting at all stages of the analysis. This will produce unbiased treatment estimate that can be generalized to the original survey population [ 26 , 52 ].…”

“…Within country policy interventions have ranged from equitable access to healthcare to the provision of quality healthcare at all levels for pregnant mothers and newborns [ 22 – 24 ]. In a similar vein, Ghana introduced one of such policies in 2008 dubbed, the ‘Free’ Maternal Healthcare Policy (FMHCP) with a primary aim of increasing facility delivery utilization and to achieve maternal and newborn care in general [ 3 , 25 , 26 ].…”

Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique

“…In line with the access to care policy, Ghana declared the ‘free’ registration of pregnant women as an exemption package of its national health insurance scheme (NHIS) in 2008 aimed at bridging the access gap to care to improve utilization of maternal health care services, thereby mitigating inequalities effect to enhance newborn care survival [ 19 , 20 ].…”