Impact of Financial and Educational Interventions on Maternity Care: Results of Cluster Randomized Trials in Rural China, CHIMACA

Abstract

To report on the design and basic outcomes of three interventions aimed at improving the use and quality of maternity care in rural China: financial interventions, training in clinical skills, and training in health education. Community-based cluster randomized trials were carried out in one central and two western provinces between 2007 and 2009: (1) financial interventions covered part of women's costs for prenatal and postnatal care, (2) training of midwives in clinical skills was given by local maternity care experts in two- or three-group training courses, (3) health education training for midwives and village doctors were given by local experts in health education in two- or three-group training courses. A survey was conducted in a stratified random sample of women who had been pregnant in the study period. 73% of women (n = 3,673) were interviewed within 1-10 months of giving birth. Outcomes were compared by the different intervention and control groups. Adjusted odds ratios were calculated by logistic regression to adjust for varying maternal characteristics. Most of the differences found between the groups were small and some varied between provinces. The financial intervention did not influence the number of visits, but was associated with increased caesarean sections and a decrease in many ultrasound tests. The clinical intervention influenced some indicators of care content. There was no consistent finding for the health education intervention. Financial and training interventions have the potential to improve maternity care, but better implementation is required. Unintended consequences, including overuse of technology, are possible.

The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review

“…One controlled before-and-after study (n = 425,708 women) and one cross-sectional study (n = 2,267 women) found no differences in uptake of antenatal care [34,40]. A retrospective area study (n = 20,133 women) of Nigeria’s SURE-P programme found no increase in receipt of any antenatal care [44] and a cluster RCT (n = 592 women) on the CHIMACA programme in China found no evidence of effect on number of antenatal contacts women received [43]. …”

“…A cluster RCT (n = 592 women) of the CHIMACA programme in China (which offered payments to women if they attended antenatal care), using 104 towns in five counties as clusters, found evidence that the programme increased caesarean section rates, which were 67.1% among intervention clusters and 56.0% among control clusters [43]. A controlled before-and-after study (n = 5,903 women) of India’s Janani Suraksha Yojana found no evidence of effect on caesarean section rates [36], however a cross-sectional study (n = 2,267) found rates increased in one state (where it was 15%) with no evidence of effect in another state [40].…”

“…One cross-sectional study (n = 23,924 women) found evidence that the same programme increased receipt of a postnatal check for women and newborns within 24 hours of birth [33] while another cross-sectional study (n = 424 women) also reported that the proportion of women and newborns who received postnatal care increased, but did not explain how postnatal care was defined or measured [37]. A cluster RCT (n = 592 women) of the CHIMACA programme found no evidence of effect on receipt of at least one postnatal contact for mothers and newborns [43]. …”

“…Four of the six data points showed a negative effect, including the largest study of 419,156 women [34]. Given this, and that all CHIMACA programme data points came from the same study [43], the evidence showed there is likely a small negative or no association between short-term payments and uptake of postnatal care.…”

“…[43] found evidence that short-term cash payments in the CHIMACA programme increased receipt of some antenatal care procedures (nutrition advice and danger signs and symptoms advice), however no evidence of effect on receipt of other procedures (blood pressure and anaemia tests).…”