Reproductive health voucher program and facility based delivery in informal settlements in Nairobi: A longitudinal analysis

Introduction: In Kenya, the maternal mortality rate had ranged from 328 to 501 deaths per 100,000 live births over the last three decades. To reduce these rates, the government launched in 2006 a means-tested reproductive health output-based approach (OBA) voucher program that covers costs of antenatal care, a facility-based delivery (FBD) and a postnatal visit in prequalified healthcare facilities. This paper investigated whether women who bought the voucher for their index child and had a FBD were more likely to deliver a subsequent child in a facility compared to those who did not buy vouchers. Methods and Findings: We used population-based cohort data from two Nairobi slums where the voucher program was piloted. We selected mothers of at least two children born between 2006 and 2012 and divided the mothers into two groups: Index-OBA mothers bought the voucher for the index child (N=352), and non-OBA mothers did not buy the voucher during the study period (N=514). The most complete model indicated that the adjusted odds-ratio of FBD of subsequent child when the index child was born in a facility was 3.89 (p<0.05) and 4.73 (p<0.01) in Group 2. Discussion and Conclusion: The study indicated that the voucher program improved poor women access to FBD. Furthermore, the FBD of an index child appeared to have a persistent effect, as a subsequent child of the same mother was more likely to be born in a facility as well. While women who purchased the voucher have higher odds of delivering their subsequent child in a facility, those odds were smaller than those of the women who did not buy the voucher. However, women who did not buy the voucher were less likely to deliver in a good healthcare facility, negating their possible benefit of facility-based deliveries. Pathways to improve access to FBD to all near poor women are needed. © 2013 Amendah et al.

This study data came from Korogocho and Viwandani, two informal settlements where the African Population and Health Research Center (APHRC) has been running the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) since 2003. Each settlement covers about one kilometer square and is located within five to 10 kilometers from the city center. The NUHDSS records demographic events (births, deaths and migration) every four months and detailed household expenditures data once a year. The Viwandani informal settlement neighbors the Industrial Area of Nairobi and was a magnet for young males and relatively educated migrants in search of work while Korogocho was home for more settled families[12], some of whom had been living there for multiple generations. As a corollary of the different demographics in both settlements, households sizes were bigger in Korogocho than Viwandani while household income per capita was higher in Viwandani [13]. As of end of 2011, the latest data available showed that 32,746 households with 83,484 individuals lived in the area covered by the NUHDSS. This surveillance system provided vital statistics and other information on a population for whom these data would otherwise be unavailable. Nested within NUHDSS was the Maternal and Child Health (MCH) project, which recruited cohorts of mother-child pairs and followed them up every four months. A mother-child pair was recruited if the mother resided in the slum when pregnant and the child was 6 months old or younger at the time of recruitment. The MCH study covered the years 2006 to 2010 with a couple of recruitment suspensions between June and September 2009 and February to June 2010. During recruitment suspensions, follow-up interviews of existing cohorts were conducted. The INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health) vaccination project (IVP) succeeded the MCH project from 2011 and took over existing cohorts of children while recruiting all children born from 2010 when recruitment into the MCH project ended. That strategy allowed for continuity in the recruitment and follow-up of children born in the slums since 2006 in the ongoing cohort studies. Both MCH and IVP projects were run by the same institution and team using the similar procedures and questionnaires so that the data quality was similar across all the rounds of data collections. The MCH/IVP projects collected information on the child’s place of delivery during the recruitment interview but the information on RH-OBA knowledge and use was collected at the second interview. Hence, information on the RH-OBA voucher was unavailable for mothers who dropped out of the MCH/IVP projects after the first recruitment interview, 22% in the MCH project and 27% in the INDEPTH Vaccination Project. This study included mother-children pairs from the MCH and the IVP datasets from 2006 to 2012. We selected mothers of at least two children, and for whom no important information—like the date of birth of the child or the mother—was missing or implausible. For twin births, we kept only one record knowing the mother’s information was the same and assuming both children were born in the same place. Since this paper focused on longitudinal effect of the voucher, we excluded women who did not buy the voucher for the index child but for the subsequent child. The APHRC owns the datasets used in this analysis. APHRC has a data sharing policy that enables other researchers to access this dataset and others. APHRC data sharing policy is available at http://www.aphrc.org/insidepage/page.php?app=data

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• Dima Health