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Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest. Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care. Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0–23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders. Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%). Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.
The Maternal Health Voucher Scheme (MHVS) of the Government of Bangladesh was initiated in 21 sub-districts in 2007, and currently operates in 53 of the country’s 556 sub-districts. A targeted voucher scheme meant for poor pregnant women (having a maximum household monthly income of Bangladeshi Taka 2500 (approximately US Dollar 30/month)) the MHVS covers three ANCs, delivery at a health facility, one PNC, management of maternal complications including caesarean delivery where required, free medicines, cash allowances for transportation, and a cash incentive to deliver at a health facility. Provider facilities and staff also receive a payment for each service provided to the scheme participants [10,21]. The voucher can be used in both public hospitals and designated private facilities. Details of the benefit package are provided in Table 1. Benefit package of MHVS. Except for medicines and registration incentives, 50% of provider reimbursement goes to a ‘seed fund’ used to improve the quality of care at the facility. The remaining 50% is distributed among people directly involved in providing services. This does not apply to private facilities where providers receive full reimbursement. A cross-sectional study was carried out during October 2016 till June 2017 to observe the difference in service utilisation between voucher and non-voucher participants in terms of utilisation of the CoC. The study was conducted in two of the low-performing (in terms of maternal health outcome) divisions of Bangladesh – Chattogram and Sylhet. In Chattogram, two sub-districts, Ramu and Teknaf, were randomly selected from the total 11 voucher areas. In Sylhet, two sub-districts, Srimongal and Salla, were randomly chosen from the five voucher areas. In both areas, public and private healthcare facilities are available to provide institutional delivery. In addition, SBAs as well as traditional birth attendants conduct home deliveries. The percentage of women delivering at home is very high in both areas (76.6% in Sylhet, 64.4% in Chattogram) compared to the national rate of 62.2% [3]. From each of the four sites in Chattogram and Sylhet, 600 women with children aged 0–23 months were selected. In the two voucher areas of Chattogram, 1446 eligible women were identified and 1200 were randomly selected for interview. In the two voucher areas of Sylhet, 1502 women were eligible and 1200 were randomly selected for interview. Finally, from all four sites, a total of 2400 women with children aged 0–23 months were interviewed. A team of 20 female interviewers with 12 years of education collected data. A four-day training was provided by the statistician to the data collection team and the questionnaire was pre-tested before data collection. Two field supervisors and one statistician supervised the data collection process. Responses were recorded directly on tablets using Open Data Kit software. Features were built into the software to reduce the likelihood of errors in data entry. To detect any anomalies, the quality control team (consisting of one quality control officer and three re-interviewers) re-visited 5% of the households, chosen randomly, within 2 days of data collection. The supervisors, data collectors and the quality control team met at regular intervals to resolve inconsistencies in the data. All completed questionnaires were checked for completeness and inconsistencies. Subsequently, the statistician used computer-based data editing procedures to confirm the quality of the data. Cluster analysis was used to allow the formation of meaningful groupings of care utilisation across the CoC using indicators for ANC, delivery and PNC. Indicator variables were created for ANC. These were whether a woman had the recommended number of ANC visits (3 or more visits) and whether a woman had some ANC care but too few visits (1–2 visits). Delivery included whether the woman had an SBA present and whether the birth took place in a facility. For PNC the variable was whether the mother received a check within 2 days of delivery. All the variables were binary, taking the values ‘1ʹ if the woman received the care and ‘0ʹ if not. A measure of dissimilarity was then created where women with similar levels of care utilisation had smaller dissimilarity and women with different care utilisation had higher dissimilarity. The cluster analysis was performed using the cluster function in Stata 13.0 for Windows using Ward’s linkage. A person-centred approach was followed to identify patterns of care for individual women within the dataset and to form meaningful care utilisation clusters that were linked to respondents’ characteristics. The person-centered approaches treat the individual as the unit of analysis, seeking to form groupings of persons with similar characteristics, rather than similar profiles of variables [22]. Once clusters within the data were identified, these were then used as response variables within a multinomial logistic regression to allow identification of the key factors predicting cluster membership. The clusters were regressed on receipt of the voucher to identify any underlying relationship between voucher receipt and care utilisation after controlling for distance to health facilities, parity, mother’s educational attainment and mother’s age. Predicted probabilities of cluster membership by voucher receipt status were generated to aid interpretation. In the absence of household income data, household ‘socioeconomic status’ was defined using an asset index. Asset information of all study participants was collected which was then used to calculate the asset index. Based on the asset index, each household was classified into quintiles where the first quintile consists of the poorest 20% of households and the fifth quintile consists of the wealthiest 20% of households [23]. For the sake of analysis, women who belonged to the bottom two asset quintiles were considered as poor, i.e. the target population for the voucher scheme. A Skilled Birth Attendant (SBA) is an ‘accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’ [24]. In rural Bangladesh, SBAs conduct deliveries both at home and at health facilities.
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