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

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.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…In Kenya, we found that wealth index was the predominant determinant of hospital birth for those from low-and middle-SES households. The Kenyan governments has implemented various propoor interventions to support the use of maternal health services since the early 2000including childbirth fees abolishment in 2007 in government dispensaries and health centres (with the replacement of a registration fee of 10-20 Kenyan Shillings, ≈ 0.1-0.2 US dollars) [39,40], and from 2006 to 2016 a reproductive health voucher programme under which poor women could purchase subsidized vouchers for 200 Kenyan Shillings to cover the cost of antenatal care, facility childbirth and postnatal care [41,42]. In 2013, the government extended the abolishment of maternity services (including childbirth) fees in all levels of government health facilities under the Free Maternity Services (FMS) policy [43].…”

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

“…Two (15.4%) studies each reported evidence from Burkina Faso and Tanzania, and one (7.7%) each reported from Niger, Sierra Leone, and Nigeria. Eight out of the 13 included studies were conducted in health facility-based settings [4,5,17,[50][51][52][53][54], two in a household-based based setting [11,55], two in community-based settings [56,57], and one was a national survey [58]. The majority (38%) of the included articles were cross-sectional studies [5,17,51,54,56], whilst the minority (8%) was quasi-experimental study design [52] (Fig.…”

“…In the present SDG era, the world targets to reduce maternal deaths to less than 70 per 100,000 live births by 2030 (SDG 3.1) [9] and free maternal healthcare services remain vital to achieving this goal [10]. Free maternal healthcare is in line with the World Health Organization's (WHO) call for countries to eliminate financial barriers and improve access to healthcare for all who need it irrespective of where one lives, work, and income level [11,12]. Free maternal healthcare financing policy can help drive the achievement of the SDG 3.1 which stipulates the reduction of maternal mortality to less than 70 per 100,000 live births by 2030 [12].…”

Influence of China’s 2009 healthcare reform on the utilisation of continuum of care for maternal health services: evidence from two cross-sectional household surveys in Shaanxi Province

“…Inequality can be further explained by decomposing the concentration index into its determining components, then horizontal inequity index (HI) can be computed by subtracting the contribution of need variables (such as women's age, health score and chronic disease) from the concentration index of CMHS utilisation; it is a summary measure of the magnitude of inequity in the dependent variable [35]. These determinants were selected according to previous research but constrained by the variables collected in the investigation [22,36]. A probit regression model was used to indirectly standardize the CMHS utilisation since the outcome variable is binary.…”