Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed

Conditional cash transfer is a social protection innovation that provides cash to poor households conditional on meeting health service requirements such as attending perinatal care, growth monitoring, and vaccinations for children or educational conditions such as school enrolment and good attendance [26]. Most of the large-scale conditional cash transfer programmes have been implemented in Latin America. In Mexico [27, 28], Nicaragua [29], and Colombia [30] the focus has been on child health and education, while in Brazil the focus included maternal health as well as child health [31, 32].There is now compelling evidence that conditional cash transfers in general increase income and overall household consumption and nutrition [33]. Furthermore, it promotes the accumulation of human capital among poor households [34] and increases access to healthcare for hard-to-reach groups [35]. Evidence about conditional cash transfer programmes strongly illustrates their effectiveness in improving access to preventative services and, sometimes, in improving health status and maternal health [36, 37]. Nonetheless, it is still not clear whether the various pathways through which the conditional cash transfers work are caused by the structure of this scheme or through behavioural changes [38]. On the other hand, the success of conditional cash transfer programmes in Latin America is not necessarily transferable to other parts of the world and their replicability in poor settings is still uncertain [38]. For example, the conditional incentive programme in Nepal for all pregnant women that encourages institutional delivery faced severe constraints in implementation at district level. These included bureaucratic delays, lack of planning and weak and inadequate health services [39].

A voucher system has been introduced as a form of demand-side funding in many settings to provide access to pre-defined services and to improve targeting of hard-to-reach populations. These redeemable coupons for a defined service package place the power of purchasing care in the hands of patients [23]. Vouchers have been used for maternal healthcare in Cambodia to improve access, quality and inequities of selected reproductive health services [40]. In India a voucher scheme, which was implemented to increase institutional delivery for emergency obstetric care for the poor, succeeded in providing substantial benefits to poor people [41]. A recent quasi-experimental trial was conducted in Eastern Uganda to study the effect of the voucher scheme on improving institutional delivery and enhancing maternal follow-up. Women in the intervention group were given booklets containing transport vouchers and service vouchers to facilitate access to free transport and free antenatal care, delivery care and postnatal care. Early results show a rapid increase in the utilisation of maternal care [42, 43]. However, while there is growing evidence to support demand-side financing, simply providing vouchers does not guarantee utilisation of services. Issues such as the wider cultural context, inequality, transportation system limitations, cost effectiveness, health system strengthening and sustainability all need to be considered and integrated [23, 43].

A community-based health insurance (CBHI) scheme is a voluntary form of health insurance that is organised at community level with the principles of risk-pooling and regular payments of a small premium [44]. It aims to prevent catastrophic health expenditure, particularly among the underserved and the poorest of the poor. Community members are involved in the management of the insurance and the selection of the health services it covers [45]. For example, in Senegal, there were 40 functioning CBHI schemes in 2004 in the Thiès region (second largest city in Senegal). The membership enrolment requires the entire nuclear families to join the scheme with a monthly premium of $0.20 to $0.40 per individual per month. Coverage of maternal health services varies, with approximately half covering prenatal care, 60 % basic delivery care, and 26 % complicated deliveries, including C-sections. [44].

Current evidence about CBHI illustrates modest achievements and enrolment challenges [46, 47], difficulty in reaching the poorest of the population [48], and challenges in financial and organisational sustainability [49]. However, the CBHI scheme can significantly contribute to financial protection, particularly if it is established as a complementary mechanism linked with social funds or the national health financing policy [46]. CBHI has been shown to increase both the demand for maternal health services and the rate of delivery with skilled birth attendants [50].

Many communities have set up and administered loan funds for emergency obstetric transport to overcome difficulties in paying for transportation. This loan funds aim to tackle the problem of insufficient funds for healthcare by the poor. It is a local system established by communities for pooling and borrowing money to cover the transportation cost during emergencies [51].

Two studies conducted in Nigeria [52, 53] showed how communities could establish and manage emergency transport funds for maternal emergencies to reduce delay in accessing emergency obstetric care. Similar community-managed emergency transport funds were implemented in Pakistan [54], Bangladesh [55‐57], and India [58]. Despite challenges, there is evidence that community transport funds and contracted transporters play a leading role in mobilising pregnant women to attend antenatal care and increase institutional delivery [43]. However, this depends on community leadership and considerable mobilisation efforts [59].

Facilitating geographical accessibility is crucial for access and utilisation of maternal care. There has been advocacy since the 1970s for appropriate intermediate modes of transport to health services in developing countries [60] that offer a locally appropriate and low cost mobility service in rural areas. Since then, many innovative, intermediate and alternative transport initiatives have been introduced to reduce the delay in referring women with maternal complications to health facilities, to reduce the cost and time of travel, and to link up with the referral system. These initiatives include motorised transport (such as motorcycles, pick-up trucks tractors and motorboats) and non-motorised transport (such as bicycles, animal drawn carts and canoes) [61]. For example, in Malawi three remote rural health centres were equipped with motorcycle ambulances to refer obstetric emergencies to the district hospital. Findings of this study found that motorcycle ambulances reduced referral delay by 35 %–76 %. Purchase price and operating costs were 19 to 24 times cheaper than for a car ambulance [62]. Linking the ambulance transportation with radio or telecommunications systems has improved referrals in many settings such as Burkina Faso [63] and Indonesia [64]. In rural Niger, prior to a radio–ambulance system, a woman with obstructed labour had no option other than to walk 75 kilometres or go by camel to reach the nearest hospital [65]. Non-motorised transport is slow, uncomfortable, occasionally culturally unacceptable and unfeasible for long distances [61]. For instance, deep cultural beliefs in rural Malawi deterred pregnant women from using a bicycle ambulance, designed to pull a wheeled trailer-stretcher, and reduced their utilisation of health facilities [66]. Recent reviews of transportation for maternal referral illustrate that motorised transports that consider cultural concerns are more likely to be an acceptable and effective choice for pregnant women during emergencies [61, 67].

Maternity waiting homes are residential facilities within easy reach of emergency obstetric care (EmOC) that aim to enhance access to care by bridging the geographical gap between women and services, and to increase institutional deliveries. These homes provide a place to stay and await labour for high-risk pregnant women or those who are living far away during the final weeks of their pregnancy. Those women have the opportunity to receive antenatal care and health education about pregnancy, delivery and neonatal care [68]. Some of these waiting homes are actually located within hospitals, as is the case in Ethiopia [69], or just next to the maternity ward, as in rural Zambia [70] and rural Timor-Leste [71]. Some of them are in accessible locations with secured transportation and communication facilities, such as some of the waiting homes in Cuba [72]. However despite studies that have reported positive effects of maternity waiting homes, utilisation of these facilities remains a challenge. Factors affecting satisfaction and utilisation include: quality of the facilities (small, crowded, poor hygiene) [73, 74]; cost of living (shortages of food, water and firewood, cost of reaching the hospital) [74, 75]; cultural issues, such as lack of awareness about the existence of the waiting homes, lack of privacy, inability to use traditional birthing practices, being away from the family and lack of respect from health staff [75, 76]; and access to services, issues here including safety concerns at night, cost of reaching the hospital and absence of healthcare personnel [75, 77]. A recent Cochrane review [68] that assessed the effects of a maternity waiting facility did not find any randomised controlled trials that evaluated the outcomes of maternity waiting homes in developing countries. The authors found wide variations between maternity waiting homes in term of facilities, location, population covered, capacity and level of care. In general there was limited reliability in terms of the study data that showed some favourable effects on outcomes for women and their newborns, but other studies indicating barriers to the utilisation of the facilities. There was insufficient evidence to determine the effectiveness of maternity waiting facilities.

Bringing healthcare to communities, through community participation and community-based interventions, is crucial for universal access to healthcare and for improving maternal and neonatal health [78]. Many approaches have been described including, for example, home visits, home management and facilitating referral [79]. Home visits involve promotion of birth and newborn-care preparedness via home-based antenatal care by female community health workers, and home-based postnatal care [80]. Another approach involves female or ‘lady’ health workers, who organise group sessions at the community to promote antenatal care, use of clean kits at delivery, institutional delivery, newborn care, danger signs identification and promotion of health-seeking behaviour [81]. In Pakistan for example, lady health workers (LHWs) from the communities in Hala and Matiari subdistricts are trained for 15 months to be able to identify all pregnant women in their area and provide to them basic antenatal care and maternal health education. They also promote use of clean delivery kits, encourage facility births and immediate newborn care. LHWs work in collaboration with voluntary community health committees and traditional birth attendants. LHWs are reimbursed for travel costs, but do not receive any financial motivation [81].

A recent Cochrane review [82] that included 18 cluster trials investigated the effects of community-based interventions in reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. The authors concluded that although skilled delivery and facility-based services for maternal and newborn care are important, the evidence is sufficient to recommend scaling up the community-based care packages.

Byrne et al. [83] in their systematic review of strategies to increase reproductive, maternal and child health in difficult to access mountainous locations categorised their findings into four main types of strategies. These included: training and improving serviced delivered through community health workers (CHWs); improving facility quality of care to make access more desirable; engaging communities; and improving health knowledge for timely care-seeking. In terms of engaging communities community-led planning was conducted in Bolivia through use of women’s groups in problem analysis, strategies and implementation of programmes resulting in improvements in health seeking behaviours. In Papua New Guinea health, education and agricultural representatives along with community leaders were involved in planning activities, though the impact of this was not evident .

Another promising approach involves women’s groups practising participatory learning and action. This includes a cycle of four phases: identification and prioritisation of maternal problems, planning for locally feasible solutions, implementation and assessment. A local woman facilitates each of these women’s groups and supports the women through a series of meetings. Interactive methods are used at these meetings, including stories, games and pictures, to discuss prevention, care seeking and treatment for common maternal and infant problems [84‐86]. In Nepal for example, a female facilitator supports nine women’s group meetings each month in a population of 7000. She facilitates the group meeting through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. These meetings enhanced demand for antenatal care and delivery by trained birth attendance. Birth outcomes improved greatly through this participatory intervention with women’s groups [84]. This bottom-up approach not only addresses how to reduce neonatal and maternal deaths but also addresses poverty, inequity, women’s empowerment and other social determinants for health [87]. A recently published systematic review and meta-analysis of the effect of women's groups practising participatory learning and action on improving maternal and newborn health in low-resource settings [88] confirmed that this approach substantially reduced neonatal and maternal deaths in rural and low-resource settings. These contextualised community-based interventions also led to significant behavioural changes and sustainable capacity development [58]. This method provides health education, based on dialogue and local problem solving, which is more effective and empowering than the message giving approach [88]. However, there are still unanswered questions, such as ‘What are the mechanisms behind the intervention effects?’ and ‘How best to promote participation?’ [87].