Maternal Health

A Cost-Effective Solution for Safe Motherhood in Kenya

Many women do not receive adequate maternal health care due to the high-cost of services, which can result in financial catastrophe for uninsured, low-income families around the world. As of 2005, the World Health Organization estimated that 44 million households spent over 40% of their expendable earnings on health care, ultimately forcing 25 million families into poverty. ¹ Health care financing through a subsidized voucher program is one possible solution to address this issue. However, the effectiveness of vouchers in actually reducing costs for individuals depends on the following: 1) whether service and transportation costs are subsidized, 2) the degree of service availability, and 3) community perceptions about the quality of care. Focusing on financial burden, a recent study examined the effects of a reproductive health vouchers program on out-of-pocket expenses for family planning, antenatal, delivery and postnatal care services in Kenya.²

Health care Spending in Kenya

Over the past decade, government spending on health care in Kenya has remained consistently lower than that of neighboring countries. As a result, out-of-pocket spending is the largest source of payment for health care services. From 1996-1999, individual payments comprised 42%-48% of total health care expenditures. This financial burden is catastrophic for 5% of Kenyan households and even drives roughly 1.5 million people into poverty annually.³

Reproductive Health Vouchers Program

The Kenyan government implemented the reproductive health vouchers program in efforts to reduce maternal and infant deaths by increasing the rates of childbirth in health facilities and improving access to health services. Essentially, by subsidizing the cost of reproductive health care, the poor are incentivized to use those services. The program consists of three components: 1) safe motherhood (focuses on pregnancy and childbirth), 2) long-term family planning, and 3) gender-based violence recovery services. Firstly, the safe motherhood voucher covers four antenatal care visits, delivery care (e.g. Caesarean section), postnatal care within six-weeks, and treatment of neonatal complications. Secondly, the family planning voucher covers long-term prevention, such as implants, intrauterine contraceptive device (IUCD), and surgical contraception. Thirdly, is a gender-based violence recovery services voucher (available to all women). Since 2006, the program is being rolled out to various communities over time.

Photo: Global Health Photo

Methods

To examine the impact of the vouchers program, two rounds of surveys were administered to neighboring counties with similar population characteristics and available health facilities.

However, one county received vouchers while the other did not. Surveys were completed from May 2010 to July 2011 by 2,933 women aged 15-49 years, and from July to October 2012 by 3,094 women of similar ages. Statistical analyses (e.g. multivariate linear regression) were then conducted to assess the difference in out-of-pocket expenses and rates of care among voucher and non-voucher communities.

Results

Use of reproductive health services

Vouchers → more women received maternal health care

Over time, more women used the safe motherhood voucher when available. This increased from 15% to 44% by 2012. These women also used private health facilities at a much higher rate than women without vouchers. However, the use of family planning vouchers did not significantly change over time, as the number of women who paid for those services remained the same.

Changes in payment for services

Vouchers → less women paid out of pocket for safe motherhood services

Women from voucher sites paid significantly less for antenatal, delivery and postnatal care services than those from non-voucher sites. While vouchers contributed to less women paying for family planning, the greatest change was related to safe motherhood services.

Table 1. The average amount paid for health services (2010 – 2012) among voucher versus non-voucher sites.

		Voucher Sites	Non-Voucher Sites
Family Planning		No change	52% Increase
Safe Motherhood	Antenatal Care	20% Decline	78% Increase
	Delivery Care	52% Decline	16% Decline
	Postnatal Care	90% Decline	40% Decline

Implications

The findings of this study suggest that increasing the use of vouchers will result in significant cost savings for women who receive reproductive health services. Marketing campaigns and increasing the number of health facilities offering vouchers can help achieve this goal. Ultimately, providing financial assistance and access to health care can protect the most vulnerable individuals from being forced into poverty.

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Photo: University of Washington, School of Public Health

References:

1. World Health Organization (WHO). Designing health financing systems to  reduce catastrophic health expenditure. Technical Briefs for Policy Makers  No. 2. Geneva: WHO; 2005.

2. Obare, F, Warren, C, Kanya, L, Abuya, T, and Bellows, B. Community-level effect of the reproductive health vouchers program on out-of-pocket spending on family planning and safe motherhood services in Kenya. BMC Health Serv Res. 2015; 15: 343.

3. Chuma J, Maina T. Catastrophic healthcare spending and impoverishment in Kenya. BMC Health Serv Res. 2012;12:413.

4. Featured image: UNFPA

830 women die from pregnancy or childbirth each day around the world.

99% of all maternal deaths occur in developing countries.

(World Health Organization)

Photo by: United Nations

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INTERNATIONAL WOMEN’S DAY

March 8^th, International Women’s Day (IWD), offers a great opportunity for people to champion gender equality as they celebrate the historical achievements of women in the social, economic, cultural and political fields (1,2).

For over a century, IWD has been recognized as a time when governments, industry, and NGOs collectively act to better women’s rights through rich and diverse activities, such as political rallies, business conferences, networking events and artistic performances. Today, we need this involvement more than ever as we move forward on a foundation of past historical success.

As we celebrate the past, we must look towards the future and continue to fight for women’s equality. There is still progress to be made, especially in regards to education, health, positions of power in business and politics, and the prevention of violence against women. The truth is clear: every girl deserves a future that is equal, safe and rewarding.

Photo by: Bill & Melinda Gates Foundation

Photo by: Medium

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WOMEN’S EQUALITY AND HEALTH

One way to close the gender inequality gap is to focus on reducing preventable maternal deaths. According to the World Health Organization (WHO), 830 women die from pregnancy or childbirth each day around the world (3). Nearly 75% of all maternal deaths are due to delivery complications, severe bleeding, infections, high blood pressure during pregnancy and unsafe abortions (5). In 2015, approximately 303,000 women died from maternal health complications, most of which could have been prevented (3).

Solutions to avoid or treat pregnancy complications are well known. It is vital that women receive prenatal and postpartum care, as well as skilled care during childbirth. However, women are unlikely to receive adequate care in remote areas and in regions with minimal skilled health workers, such as sub-Saharan Africa. In 2015, only 40% of pregnant women in low-income countries had received the four recommended antenatal care visits (3). Other factors that inhibit women from seeking or receiving care include poverty, distance, inadequate services, cultural practices and lack of information. These barriers must be addressed at all levels of the health system in order to tackle maternal mortality. The timely diagnosis and management of pregnancy related complications is a matter of life or death for the mother and baby.

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Photo by: Erin Goodrow

Photo by: New Security Beat

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THE SUSTAINABLE DEVELOPMENT GOALS

On September 25^th, 2015, member states of the WHO adopted the Sustainable Development Goals (SDGs) with 15-year targets to end poverty and ensure prosperity for all (4). One objective is to reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 births (3). However, 99% of all maternal deaths occur in developing countries, reflecting the inequities in access to health services. For example, the MMR in 2015 was 239 per 100,000 live births in developing countries versus 12 per 100,000 live births in developed countries. Additionally, over half of the global maternal deaths occur in sub-Saharan Africa, particularly among rural and low-income communities. Overall, women in developing countries have many more pregnancies and have a higher risk of death due to pregnancy. The probability that a 15-year-old woman will die from a maternal cause is 1 in 180 in developing countries versus 1 in 4,900 in developed countries (3). In order to achieve the SDGs, women need greater access to reproductive health services, especially those in low-resource settings.

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PRIORITIZING MATERNAL HEALTH

WHO and numerous organizations have been working to reduce maternal mortality rates by increasing research, providing evidence-based clinical guidance, setting global standards and delivering technical support. During the United Nations General Assembly in 2015, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) was launched as a road map for the post-2015 agenda presented in the SDGs. The aim is to end all preventable deaths of women, children and adolescents, as well as provide an environment for health to thrive. In order to implement this strategy, WHO and partners are working on the following regarding reproductive, maternal and newborn health care: addressing inequalities in access to services, ensuring universal health coverage, addressing causes of maternal mortality and morbidities, strengthening health systems and ensuring accountability for quality care.

For efforts to succeed, the world must unite in prioritizing maternal health. Advocates, organizations, and governments need to take a stand against women’s inequality and provide greater agency, support and resources towards tackling maternal mortality.