Introduction

The maternal mortality ratio (MMR) in Bangladesh has substantially decreased from 322 deaths per 100,000 livebirths in 1998–2001 to 194 deaths per 100,000 livebirths in 2007–10 [1]. The neonatal mortality rate also declined from 41 per 1,000 livebirths in 1999–2003 to 28 per 1,000 livebirths in 2010–14 [2]. Despite this progress, the numbers of maternal and neonatal deaths remained high. Delivering at health facilities can prevent many of these unnecessary deaths [3–7]. Nonetheless, utilization of health facilities for delivery care, which is a proxy for use of skilled obstetric care, is still quite low in Bangladesh [2]. In Bangladesh, the proportion of mothers delivering in health facilities has been persistently low (29 percent in 2011 and 37 percent in 2014), but the rates are even lower in rural areas (31 percent in 2014) among the poorest quintile of the population (15 percent in 2014) and in Sylhet (23 percent in 2014), which is one of the eight administrative divisions in Bangladesh [2]. The maternal and neonatal mortality rates are higher in these sub-populations. In 2010, compared to the national average MMR of 194 per 100,000 livebirths, the MMR was 199 per 100,000 livebirths in rural populations, 234 per 100,000 livebirths in the poorest quintile and 425 per 100,000 livebirths in the Sylhet division [1]. The neonatal mortality rate in the year 2014 was 31 per 1,000 livebirths in rural populations, 35 per 1,000 livebirths in the lowest wealth quintile and 39 per 1,000 livebirths in the Sylhet division [2].

There are several factors in the healthcare system that may influence a woman's ability to access appropriate care during pregnancy and child birth. Thaddeus and Maine [8] developed a three delays model about two decades ago to evaluate the circumstances surrounding access to skilled attendance at delivery. The authors defined the factors, chronologically, as the lengths of the delays in (i) the decision to access care, (ii) reaching an adequate health care facility, and (iii) the receipt of adequate and appropriate care. Distance to health facilities, lack of transport, inadequate financial resources to access care, and poor-quality care, which are often interlinked, are fairly common problems in resource-poor settings such as Bangladesh [9–13]. Women, particularly in rural areas, often prefer to deliver at home rather than embarking on a long and difficult journey to poorly attuned public health facilities that often suffer from shortages of supplies, equipment and trained personnel, leading to poor quality of care [14–17]. In many public health facilities, patients have to pay out-of-pocket for everything, including unofficial user fees [18–22]. While delivery is the single most costly event during pregnancy, the cost of complicated deliveries is often catastrophic, which can force poor households into deeper economic hardship and poverty [23, 24]. Furthermore, many social factors may influence the decision to seek care, such as lack of awareness of the value of maternal health services, lack of information of sources of care, cultural norms and beliefs system, traditional practices that include a preference for birthing at home, and requiring permission from family decision makers [9, 14, 25].

Given the complexity of these barriers, it is suggested that interventions aiming at improving maternal health outcomes need to be multi-pronged and comprehensive so that they explicitly address both health service constraints on the supply side as well as contextual factors, for example, socio-economic and demographic factors and cultural and knowledge barriers on the demand side [26, 27]. Maternal health vouchers and other innovative financing initiatives have been employed in many impoverished settings in recent years and have successfully increased deliveries with skilled birth attendants and institutional deliveries [28–38]. In this paper, we report the effect of an integrated demand- and supply-side intervention undertaken as part of an ongoing maternal and newborn health improvement study on facility delivery rates over a 24-month period in a rural population in Sylhet district, Bangladesh.

Methods

Results

We present here the numbers of deliveries among women enrolled in the AMANHI biorepository study by place of delivery during the period of December 2014 to November 2016 (Fig 1). There was a statistically significant increase in the facility delivery rate over the study period (p < .0001). Thirty abortion cases, either spontaneous or induced, were excluded from the analysis. Overall, out of 1,861 deliveries, 624 deliveries (33.5 percent) occurred at home whereas 1,218 deliveries (65.4 percent) occurred in a health facility. Among the 1,218 institutional deliveries, the number of women who delivered in UH&FWCs was 117 (9.6 percent), in UHCs 687 (56.4 percent), in SOMCH 280 (23.0 percent) and in NGO/private hospitals130 (10.7 percent). Four deliveries (0.3 percent) were reported to taken place in a health facility but the names or types of the facilities are missing. In addition to these, there were 19 deliveries that occurred in places other than home or a health facility including on the way to a hospital.

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Fig 1. Study flow chart.

https://doi.org/10.1371/journal.pone.0186182.g001

The level of institutional delivery was quite low in the initial two months (25.0 percent in each of the months of December 2014 and January 2015) but rose to 47.1 percent in February 2015, which coincided with the start of the cash financial incentive initiative to cover expenses of accessing facility care for child birth (February 2015) as well as the deployment of a dedicated ‘maternity vehicle’ in the same month for transportation of pregnant women to the nearest health facility (Fig 2). The proportion of women delivering in a health facility increased further to 55.9 percent in March 2015 and then remained relatively stable up to December 2015 at approximately 55.0 percent, except for the month of Holy Ramadan (June-July 2015) when the response for health facility deliveries was relatively lower (41.9 percent).

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Fig 2. Trends in proportions of pregnant women delivered in a health facility.

https://doi.org/10.1371/journal.pone.0186182.g002

An additional increase in the level of institutional delivery among women was observed in January 2016 with a 12.4 percentage point increase from that in December 2015 (71.1 percent vs. 58.7 percent). The maximum increase in the proportion of institutional delivery occurred in February 2016 (83.9 percent) and then remained steady at approximately 74.0 percent in the subsequent months. Overall, there was a 52.6 percentage point increase in the proportions of institutional deliveries between December 2014 (25.0 percent) and November 2016 (77.6 percent) in the study population.

Discussion

In this population-based cohort of Bangladeshi women, the institutional delivery rate increased from 25.0 percent to 77.6 percent in 24 months. We observed that implementation of a set of integrated supply- and demand-side interventions was associated with a substantial increase in the utilization of health facilities for birthing care in a rural population of Bangladesh, which is consistent with the findings from other similar interventions including demand-side financing voucher programs in many other settings [27, 28, 32, 34, 36–38, 43–46]. We carried out this study in Kanaighat and Zakiganj sub-districts of Sylhet district, Bangladesh, and they were not included in the ongoing maternal health voucher scheme commonly known as the Demand-Side Financing (DSF) program, initiated by the Government of Bangladesh in 2007 [29–31]. To our knowledge, there were no other competing programs within our intervention areas that subsidized the cost of accessing services and can explain the changes that we have observed in our study.

The government of Bangladesh, since the 1980s, has been providing core services for maternal and child health for the rural population through district hospitals, UHCs, UH&FWCs, community-based skilled birth attendants (CSBAs) and community clinics. Guided by a number of global and national policies, plans and strategies, which have yet to realize their potentials, Bangladesh has primarily emphasized setting up health centers/hospitals, providing service training and upgrading equipment and supplies to improve the quality of health care [47]. To date, the financing of maternal health services in Bangladesh is largely supply based [29, 48], is not directly linked to the quantity of services, and does not consider the provider’s ability to reach the poorer sections of the community. At the community level, Family Welfare Assistants (FWAs) are responsible for delivering the domiciliary services that include providing ANC and referral of high-risk pregnancies alongside their family-planning tasks. However, although these workers are slated to make home visits every 2–3 months, only 20% of currently married women reported that they were visited by a fieldworker in the last 6 months [2]. A number of non-governmental organizations (NGOs) are playing a complementary role to the overall performance of the national maternal, child health and family planning (MCH-FP) program in Bangladesh. Nonetheless, they are mostly involved in the provision of primary healthcare at the grassroots level and do not adequately address barriers to access to appropriate obstetric care. Hence, despite significant improvements in the healthcare delivery infrastructure, access to maternal health services including facility-based delivery care in Bangladesh remained low [27, 47, 49].

The apparent failure of the supply-side strategy to reach the poor has prompted the governments, practitioners and funders in many countries to employ demand-side financing (DSF) including maternal health voucher schemes to encourage utilization of essential maternal health services. There have been emerging findings of increased uptake of institutional delivery or skilled attendance at birth associated with the DSF schemes from different parts of the world [28, 29, 32–38, 46]. In Bangladesh, the Ministry of Health and Family Welfare, with pooled funds from various sources and technical support from the WHO, started the implementation of the DSF maternal health voucher program in 33 sub-districts in 2007, which covered a population of approximately 10 million people [26, 27, 29–31]. The service components covered by the vouchers are transport costs, vouchers for antenatal care, safe delivery at home or in a facility, emergency care for complications, and postnatal care, plus a gift and cash incentive for delivery with a qualified provider. Women received up to Taka 500 (US $7.29) for routine transport costs, Taka 500 for emergency transport, a gift box worth Taka 500, and a Taka 2000 (US $29.18) cash incentive after delivering with a qualified provider (exchange rate in 2009: US $1 = Taka 68.55) [25, 29, 30]. In addition to this, the health care facilities as well as the providers received incentives for providing voucher-covered obstetric services at the following rates: Taka 300 (US $4.3) for a normal delivery, Taka 1000 (US $14) for forceps/vacuum, Taka 100 (US $1.4) for medicine, Taka 1000 (US $14) for management of eclampsia, and Taka 6000 (US $86) for a C-section. The average cost per voucher distributed (based upon the direct costs of the DSF program) is estimated to be US $41, which includes incentives to pregnant women as well as to providers and facilities in addition to the program administrative costs [31]. The DSF program in Bangladesh has shown that the women who received the intervention had an 18.8 percentage points increase in institutional deliveries (37.5 percent in DSF program sub-districts compared to 18.7 percent in control sub-districts) and 36.6 percentage points increase in use of a skilled provider during delivery (63.7 percent in DSF program sub-districts compared to 27.1 percent in control sub-districts) during the initial two years of the intervention [31].

Under a national conditional cash transfer (CCT)-based program known as Janani Suraksha Yojana (JSY) in India [32, 33, 45], all pregnant women in 18 high-focus states received a 1,400 rupee (US $28) cash incentive after delivery in a government or accredited private health facility. In addition, the community-level health workers received payments of 600 rupees (US $12) per delivery assisted by them. The JSY program reported a 42.6 percentage point increase in facility-based delivery after implementation [33]. A maternal health voucher scheme in Pakistan reported that purchase of a voucher booklet (valued at US$50; were sold for US$1.25 to low-income women targeted by project workers) containing redeemable coupons for three antenatal care visits, a postnatal care visit and institutional delivery was associated with a 22.1 percentage point increase in institutional delivery [43]. Poel et al. described an increased probability (10.1 percentage point increase) of having delivery in a public health-care facility following the implementation of a maternal voucher scheme in Cambodia [37]. A combined supply- and demand-side intervention in Uganda has demonstrated a substantial increase in the number of facility births (from <200 deliveries/month to over 500 deliveries/month) [36]. Bellows et al. found that allowing eligible women in Kenya to purchase vouchers that covered antenatal care, facility-based delivery, and postnatal care resulted in significantly greater odds of a facility-based delivery (OR: 1.4 (1.2–1.6)) among respondents, compared with similar respondents prior to voucher launch [38]. A similar result has been reported from rural Burkina Faso, with increased facility-based delivery rates from 49 to 84 percent during the intervention period when women were offered 80 percent subsidy for facility-based deliveries [46].

In our study, we observed a 52.6 percentage point increase in facility-based delivery after implementation of an integrated supply- and demand-side intervention over a 24 month period. The study is ongoing and the cost-effectiveness of the project, including average cost per institutional delivery, is yet to be evaluated; however, the total incentive we provided was comparable to the national program described above. In the first step of our intervention during October-December 2014, we made attempts to improve the quality and responsiveness of the service provision in three designated public health facilities. Upgrading and renovation of the health facilities were done as described earlier. Adding to this, the project deployed trained nurses and support staff to ensure 24/7 service coverage in all the designated health facilities. Nonetheless, despite the capacity expansion of the designated healthcare facilities, there were no visible improvements in the uptake of institutional birth among enrolled pregnant women until February 2015, when we addressed the financial barriers by introducing cash incentive payments to families and service providers. This may have reinforced the fact that supply-side interventions alone are not adequate to increase utilization of health care services in the low-utilization areas [5, 8, 50, 51], and financial barriers to access must be addressed.

In February 2015, the project emphasized the generation of demand among the women and their families, combined with lowering financial barriers to accessing institutional delivery care, through the arrangement of a series of advocacy meetings involving the community leaders and stakeholders, comprehensive birth planning counseling involving the family decision makers, the provision of cash incentives for giving birth in a health facility and the arrangement of emergency transport, including provision of a full-time dedicated ‘maternity vehicle’. Employment of this comprehensive demand-side intervention may have influenced the relative increase in the proportions of institutional deliveries in February 2015 (47.1 percent vs. 25.0 percent in January 2015), which have further increased in the following months. On the other hand, provision of a referral support for the complicated deliveries to a tertiary level hospital (i.e., SOMCH) was believed to help build a level of confidence and trustworthiness among the enrolled women and their families that may have enhanced the demand generation for delivering a child in any of the study-designated health facilities.

We have observed a steady trend in the proportions of institutional deliveries among enrolled women at approximately 53 percent throughout the year 2015, which rose to approximately 75 percent in the year 2016. A possible explanation for this increase could be that any new concerted effort to ameliorate maternal care seeking through supply- and demand-side interventions such as ours needs time to gain momentum, because it supposedly takes time for both the recipients and the service providers to become accustomed to the incentive scheme [27].

The intervention was novel and complex as well because it incorporated several activities in the community and intervened within the formal health care delivery system in a rural setting. It involved not only the family decision makers but also the traditional birth attendants, community resource persons and stakeholders and emphasized social approval and its ability to bring about changes in behavior. It targeted creating awareness of the value of maternal health services and providing information of sources of skilled obstetric care to the families. The project offered emergency transport available at the doorsteps of the rural households, which has gradually become popular and well-accepted among the recipients. It incorporated capacity expansion of healthcare facilities, allowing additional incentive payments to public health care providers, increased uptake through financial incentives to the households that reduce the cost of accessing services and developed effective referral systems for complicated cases to a tertiary care hospital.

The study had a number of limitations. This observational study within the context of an epidemiological study was based on a before-and-after design and did not have a concurrent control group. Therefore, it is harder to rule out the possibility that the observed increase in facility-based deliveries was influenced by the existence of another intervention or program or some other confounder. Another potential limitation is that we have recruited only a subset of pregnant women who met the study enrollment criteria in a relatively small total population of 120,000, which makes it difficult to draw confident conclusions about the generalizability of the intervention package. Moreover, in our study, we did not analyze the cost-effectiveness of the intervention, particularly the incremental cost per additional delivery in a public health facility that is required to facilitate health policy and decision making. We provided service training and upgraded equipment and supplies, but we do not have any additional data on quality of health care in the health facilities, which could be helpful. It is also difficult to determine which of the various strategies was more effective, because the intervention was integrated and provided as a package.

Conclusions

This study provides evidence that integrated supply- and demand-side interventions addressing the access barriers can result in rapid increases in the utilization of facility-based services for maternity care in a resource-poor setting. Further improvements in maternal care seeking can be achieved if such a comprehensive approach explicitly addresses the transport difficulties in a rural context and gives ample consideration to the needs for a referral back-up for complicated deliveries. The study assembled various intervention designs and strategies that can be tailored to identify what combination of interventions may produce the optimum result. The tailored package needs to be implemented in a large-scale program using rigorous implementation research studies to draw confident conclusions on the impact of supply- and demand-side financing initiatives and provide information about their costs, feasibility and sustainability in order to make corresponding policy recommendations.

Supporting information

Acknowledgments

We acknowledge with gratitude the overall technical support of the World Health Organization (WHO) Department of Maternal, Newborn, Child and Adolescent Health for implementation of this research study. The Projahnmo study group consisted of the Johns Hopkins Bloomberg School of Public Health, Bangladesh Ministry of Health and Family Welfare, International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), Child Health Research Foundation (CHRF), and Shimantik (a local NGO). We are also grateful to the study communities, particularly the mothers, for agreeing to participate in this study and to the anonymous individuals and staff members for their unabated diligence and efforts. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.