Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda. Newborn Infection Control and Care Initiative for health facilities to accelerate reduction of newborn mortality (NICCI): study protocol for a randomized controlled trial Income Transfers and Maternal Health: Evidence from a National Randomized Social Cash Transfer Program in Zambia. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades Effects of a Large-Scale Unconditional Cash Transfer Program on Mental Health Outcomes of Young People in Kenya. The impact of Mexico's conditional cash transfer programme, Oportunidades, on birthweight. Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor. An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme. Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the global network's EmONC trial) Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings Impact of an SMS advice programme on maternal and newborn health in rural China: study protocol for a quasi-randomised controlled trial Conditional Cash Transfers And Health Of Low-Income Families In The US: Evaluating The Family Rewards Experiment. Ethical and practical issues relating to the global use of therapeutic hypothermia for perinatal asphyxial encephalopathy Acceptability and trust of community health workers offering maternal and newborn health education in rural Uganda. Cash Transfers to Increase Antenatal Care Utilization in Kisoro, Uganda: A Pilot Study. Continuum of Care Services for Maternal and Child Health using mobile technology – a health system strengthening strategy in low and middle income countries Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya Yo Puedo--a conditional cash transfer and life skills intervention to promote adolescent sexual health: results of a randomized feasibility study in san francisco. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan Cash transfers and domestic violence. What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries.
Background Dem and -side financing projects are now being implemented in many developing countries , yet evidence showing that they reach the poor is scanty . Methods A  maternal health voucher scheme provided voucher-paid services in Jhang , a predominantly rural district of Pakistan , during 2010 . A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor . Household interviews were conducted with r and omly selected women in the intervention and control union councils , before and after the intervention . A strong outreach model was used . Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan , in the types of problems women could face during delivery , and in the promotion of antenatal care ( ANC ) , institutional delivery and postnatal care ( PNC ) . Voucher booklets valued at Rs . 4,000 ( $ 48 ) , including three ANC visits , a PNC visit , an institutional delivery , and a postnatal family planning visit , were sold for Rs . 100 ( $ 1.2 ) to low-income women targeted by project outreach workers . Women suffering from complications were referred to emergency obstetric care services . Analysis was conducted at the bivariate and the multivariate levels . At the multivariate level , logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women ( defined for this study as women in the fourth or fifth quintiles ) relative to non-poor women ( defined for this study as women in the first quintile ) in the intervention union councils compared to the control union councils . Results Bivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils . Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils . Conclusions Dem and -side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery The maternal mortality ratio ( MMR ) in Ug and a has declined significantly during the last 20 years , but Ug and a is not on track to reach the millennium development goal of reducing MMR by 75 % by 2015 . More evidence on the cost-effectiveness of supply- and dem and -side financing programs to reduce maternal mortality could inform future strategies . This study analyses the cost-effectiveness of a voucher scheme ( VS ) combined with health system strengthening in rural Ug and a against the status quo . The VS , implemented in 2010 , provided vouchers for delivery services at public and private health facilities ( HF ) , as well as round-trip transportation provided by private sector workers ( bicycles or motorcycles generally ) . The VS was part of a quasi-experimental non-r and omized control trial . Improvements in institutional delivery coverage ( IDC ) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence -based Lives Saved Tool . Costs were estimated from primary and secondary data . Results show that the dem and for births at HFs enrolled in the VS increased by 52.3 percentage points . Out of this value , conservative estimates indicate that at least 9.4 percentage points are new HF users . This 9.4 % bump in IDC implies 20 deaths averted , which is equivalent to 1356 disability-adjusted-life years ( DALYs ) averted . Cost-effectiveness analysis comparing the status quo and VS 's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$ 302 and per death averted of US$ 20 756 . Although there are limitations in the data measures , a favourable cost-effectiveness ratio persists even under extreme assumptions . Dem and -side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable Background Newborn health is a key issue in addressing the survival of children under five years old , particularly in low and middle income countries , and the evidence base for newborn health interventions continues to evolve . Over the last decade , maternal and under five-year-old mortality and morbidity rates have been successfully reduced in Cambodia , but newborn health has lagged behind . Evidence suggests that an important proportion of newborn mortality both globally and in Cambodia is attributable to infections and sepsis . While initiatives are being implemented to address some causes of newborn illness ( related to pre-term birth and asphyxia ) , a country-level approach to reducing infections has not been formulated . The Newborn Infection Control and Care Initiative ( NICCI ) is a community and health facility linked intervention to improve health outcomes for newborns . Methods / Design The present study applies a cluster r and omized trial , using a stepped wedge design , to assess the impact of a package intervention on  newborn health . The intervention components include addressing infection control in the perinatal period in health facilities , promoting infection prevention and control practice s in health center and home environments , and improving the timeliness of referrals for newborns with suspected infections to appropriate health facilities , by linking families to the medical system through a network of community based volunteers who will make home visits to families in the first week of a newborn ’s life . Discussion The NICCI trial is design ed to complement and enhance the Cambodian Ministry of Health strategies and objectives for maternal and newborn care . Results of the study will help to inform policy and the possible scale-up of newborn health interventions in the country . Trial registration This trial was registered with Clinical trials.gov ( identifier : NCT02271737 ) on 5 October 2014 There is promising recent evidence that poverty-targeted social cash transfers have potential to improve maternal health outcomes ; however , questions remain surrounding design features responsible for impacts . In addition , virtually no evidence exists from the African region . This study explores the impact of Zambia 's Child Grant Program  on a range of maternal health utilization outcomes using a r and omized design and difference-in-differences multivariate regression from data collected over 24 months from 2010 to 2012 . Results indicate that while there are no measurable program impacts among the main sample , there are heterogeneous impacts on skilled attendance at birth among a sample of women residing in households having better access to maternal health services . The latter result is particularly interesting because of the overall low level of health care availability in program areas suggesting that dedicated program design or matching supply-side interventions may be necessary to leverage unconditional cash transfers in similar setting s to impact maternal health BACKGROUND Many governments have implemented conditional cash transfer ( CCT ) programmes with the goal of improving options for poor families through interventions in health , nutrition , and education . Families enrolled in CCT programmes  receive cash in exchange for complying with certain conditions : preventive health requirements and nutrition supplementation , education , and monitoring design ed to improve health outcomes and promote positive behaviour change . Our aim was to disaggregate the effects of cash transfer from those of other programme components . METHODS In an intervention that began in 1998 in Mexico , low-income communities ( n=506 ) were r and omly assigned to be enrolled in a CCT programme  ( Oportunidades , formerly Progresa ) immediately or 18 months later . In 2003 , children ( n=2449 ) aged 24 - 68 months who had been enrolled in the programme their entire lives were assessed for a wide variety of outcomes . We used linear and logistic regression to determine the effect size for each outcome that is associated with a doubling of cash transfers while controlling for a wide range of covariates , including measures of household socioeconomic status . FINDINGS A doubling of cash transfers was associated with higher height-for-age Z score ( beta 0.20 , 95 % CI 0.09 - 0.30 ; p<0.0001 ) , lower prevalence of stunting ( -0.10 , -0.16 to -0.05 ; p<0.0001 ) , lower body-mass index for age percentile ( -2.85 , -5.54 to -0.15 ; p=0.04 ) , and lower prevalence of being overweight ( -0.08 , -0.13 to -0.03 ; p=0.001 ) . A doubling of cash transfers was also associated with children doing better on a scale of motor development , three scales of cognitive development , and with receptive language . INTERPRETATION Our results suggest that the cash transfer component of Oportunidades is associated with better outcomes in child health , growth , and development PURPOSE This study investigates the causal effect of Kenya 's  unconditional cash transfer program on  mental health outcomes of young people . METHODS Selected locations in Kenya were r and omly assigned to receive unconditional cash transfers  in the first phase of Kenya 's Cash Transfer Program for orphans and Vulnerable Children . In intervention locations , low-income households and those with orphans and vulnerable childrens began receiving monthly cash transfers of $ 20 in 2007 . In 2011 , 4 years after program onset , data were collected on the psychosocial status for youth aged 15 - 24 years from households in intervention and control locations ( N = 1960 ) . The primary outcome variable was an indicator of depressive symptoms using the 10- question Center for Epidemiologic Studies Depression Scale . Secondary outcomes include an indicator for hopefulness and physical health measures . Logistic regression models that adjusted for individual and household characteristics were used to determine the effect of the cash transfer program . RESULTS The cash transfer reduced the odds of depressive symptoms by 24 percent among young persons living in households that received cash transfers . Further analysis by gender and age revealed that the effects were only significant for young men and were larger among men aged 20 - 24 years and orphans . CONCLUSIONS This study provides evidence that poverty-targeted unconditional cash transfer programs , can improve the mental health of young people in low-income countries OBJECTIVES To evaluate the impact of Oportunidades , a large-scale , conditional cash transfer programme in Mexico , on  birthweight .  The programme provides cash transfers to low-income , rural households in Mexico , conditional on accepting nutritional supplements health education , and health care . METHODS The primary analyses used retrospective reports from 840 women in poor rural communities participating in an effectiveness study and r and omly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states . Pregnant women in participating households received nutrition supplements and health care , and accepted cash transfers . Using multivariate and instrumental variable analyses , we estimated the impact of the programme on birthweight in grams and low birthweight ( < 2500 g ) , receipt of any pre-natal care , and number of pre-natal visits . RESULTS Oportunidades beneficiary status was associated with 127.3 g higher birthweight among participating women and a 4.6 percentage point reduction in low birthweight . CONCLUSION The Oportunidades conditional cash transfer programme improved birthweight outcomes . This finding is relevant to countries implementing conditional cash transfer programmes BACKGROUND Caesarean section rates are increasing in Mexico and Latin America . This study evaluates the impact of a large-scale , conditional cash transfer programme in Mexico on caesarean section rates . The programme provides cash transfers to participating low income , rural households in Mexico conditional on accepting health care and nutrition supplements . METHODS The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and r and omly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states . Using multivariate and instrumental variable analyses , we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting . Programme participation is measured by beneficiary status , programme months and cash transfers . RESULTS More than two-thirds of poor rural women delivered in a health facility . Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates ; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for > or=6 months before delivery . Beneficiaries had significantly higher caesarean delivery rates in social security facilities ( 24.0 compared with 5.6 % among non-beneficiaries ) and in other government facilities ( 19.3 compared with 9.5 % ) . CONCLUSION The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities . This effect appears to be driven by the increases in disposable income from the cash transfer . These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements Maternal health services continue to favour the wealthiest in lower and middle income countries . Debate about the potential of performance-based financing ( PBF ) to address these disparities continues . As PBF is adopted by countries , it is critical to underst and the equity effects for maternal services . The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population . In Rw and a , PBF was design ed to increase health service use , which was universally low . Paired districts were r and omly assigned to intervention and control for PBF implementation . Using Rw and a 's Demographic Health Survey data from 2005 ( pre-intervention ) and 2007 - 8 ( post-intervention ) , a cluster-level panel data set of 7899 women 15 - 49 years of age from intervention ( 4477 ) and control districts ( 3422 ) was created . The impact of PBF on reported use of facility deliveries , antenatal care ( ANC ) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects . Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women . The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts ( P = 0.014 ) , while no significant effects were noted for ANC visits or modern contraceptive use . Service use increased for intervention and control population s and across all wealth quintiles from 2005 to 2007 , with no evidence that PBF was a pro-poor or a pro-rich strategy . Insurance remained a positive predictor of service use . This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services , such as facility deliveries , may improve service use overall . However , if the equity gap is extreme , then a PBF programme without equity targets will do little to alleviate disparities OBJECTIVES To evaluate the impact of Mexico 's conditional cash transfer programme on the quality of health care received by poor women . Quality is measured by maternal reports of prenatal care procedures received that correspond with clinical guidelines . METHODS The data describe retrospective reports of care received from 892 women in poor rural communities in seven Mexican states . The women were participating in an effectiveness study and r and omly assigned to incorporation into the programme in 1998 or 1999 . Eligible women accepted cash transfers conditional on obtaining health care and nutritional supplements , and participated in health education sessions . RESULTS Oportunidades beneficiaries received 12.2 % more prenatal procedures compared with non-beneficiaries ( adjusted mean 78.9 , 95 % Confidence Interval ( CI ) : 77.5 - 80.3 ; P < 0.001 ) . CONCLUSION The Oportunidades conditional cash transfer programme is associated with better quality of prenatal care for low-income , rural women in Mexico . This result is probably a manifestation of the programme 's empowerment goal , by encouraging beneficiaries to be informed and active health consumers Background Maternal and newborn mortality rates remain unacceptably high , especially where the majority of births occur in home setting s or in facilities with inadequate re sources . The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes . However , the effectiveness of emergency obstetric and neonatal care services has never been proven . Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes . Methods / Design We have developed a cluster-r and omized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization , birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities . This trial will take place in 106 clusters ( 300 - 500 deliveries per year each ) across 7 sites of the Global Network for Women 's and Children 's Health Research in Argentina , Guatemala , India , Kenya , Pakistan and Zambia . The trial intervention has three key elements , community mobilization , home-based life saving skills for communities and birth attendants , and training of providers at obstetric facilities to improve quality of care . The primary outcome of the trial is perinatal mortality . Secondary outcomes include rates of stillbirth , 7-day neonatal mortality , maternal death or severe morbidity ( including obstetric fistula , eclampsia and obstetrical sepsis ) and 28-day neonatal mortality . Discussion In this trial , we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes . If successful , the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries . Trial Registration Clinical Trials.gov Objective : Immediate Kangaroo Mother Care ( KMC ) , an intervention following childbirth whereby the newborn is placed skin-to-skin ( STS ) on mother 's chest to promote thermal regulation , breastfeeding and maternal-newborn bonding , is being taught in very low-income countries to improve newborn health  and survival . Existing data are review ed to document the association between community-based KMC ( CKMC ) implementation and its potential benefits . Study Design : New analyses of the sole r and omized controlled study of CKMC in Bangladesh and others ' experiences with immediate KMC are presented . Result : Newborns held STS less than 7 h per day in the first 2 days of life do not experience substantially better health or survival than babies without being held STS . Conclusion : Most women who were taught  CKMC  hold their newborns STS , but do so in a token manner unlikely to improve health or survival . Serious challenges exist to provide effective training and postpartum support to achieve adequate STS practice s. These challenges must be overcome before scaling up Introduction Expectant mothers in low-income and middle-income countries often lack access to vital information about pregnancy , preparation for birth and best practice s when caring for their newborn . Innovative solutions are needed to bridge this knowledge gap and dramatically improve maternal and neonatal health in these setting s. This study aims to evaluate the impact of an innovative text messaging intervention on maternal and neonatal health outcomes . Methods and analysis This study offers expectant mothers in rural China a package of free short messages via cell phone regarding pregnancy and childbirth . These messages are tailored to each mother 's gestational week . It is hypothesised that delivering these short advice messages to pregnant women can improve maternal and newborn health . The study uses factorial quasi-r and omisation to compare psychological , behavioural and health outcomes between 4 groups : 2 groups receiving different sets of short message interventions ( ie , good household prenatal practice s and healthcare seeking ) , a group receiving both interventions and a control group . Treatment assignment occurs at the individual level . The primary outcome is newborn health , measured by appropriateness of weight for gestational age . Secondary outcomes include severe neonatal and maternal morbidity as well as psychological and behavioural measures . This study has enrolled pregnant women who attend county maternal and child health centres for their prenatal visits . Discussion This pilot is the first large-scale effort to build a comprehensive evidence base on the impact of prenatal text messages via cell phone on maternal and newborn health outcomes in China . The study has broad implication s for public health policy in China and the implementation of mobile health interventions in low-re source setting s around the world . Ethics This study was approved by the Ethics Committee of the School of Medicine at Xi'an Jiaotong University on 18 January 2013 . Trial registration number NCT02037087 ; Pre- results Opportunity  NYC-Family Rewards was the first conditional cash transfer , r and omized controlled trial for low-income families in the United States . From 2007 to 2010 , Family Rewards offered 2,377 New York City families cash transfers  that were conditional upon their investments in education , preventive health care , and parental employment . Their health and other outcomes were compared to those of a  control group of 2,372 families . The experiment led to a modest improvement in health insurance coverage and a large increase in the use of preventive dental care . It improved parents ' perception of their own health and levels of hope , mainly through improvements in reported financial well-being . While the program 's impacts on physical health were weaker , our study might not have captured effects on chronic disease risk that take longer to accrue . In the context of New York City 's operating social-safety-net programs , conditional cash transfers may have led to positive , albeit modest , improvements in the health of poor families In intensive care setting s in the developed world , therapeutic hypothermia is established as a therapy for term infants with moderate to severe neonatal encephalopathy due to perinatal asphyxia . Several pre clinical , pilot and clinical trials conducted in such setting s over the last decade have demonstrated that this therapy is safe and effective . The greatest burden of birth asphyxia falls , however , in low- and middle-income countries ; it is still unclear whether therapeutic hypothermia is safe and effective in this context . In this paper , the issues around treatments that may be proven safe and effective in the developed world and the caution needed in translating these into different setting s and population s are explored . It is argued that there are strong scientific and ethical reasons supporting the conduct of rigorous , r and omised controlled trials of therapeutic hypothermia in middle-income setting s. There also needs to be substantial and sustainable improvements in all facets of antenatal care and in the basic level of newborn resuscitation in low income countries . This will reduce the burden of disease and allow health workers to determine rapidly which infants are most eligible for potential neuroprotection When trusted , Community Health Workers ( CHWs ) can contribute to improving maternal and newborn health outcomes in low- and middle-income countries through education . Issues of acceptability of CHWs by communities were explored through experiences gained in a qualitative study that is part of a cluster r and omized trial in East Ug and a. Initially , focus group discussion s with key community members and leaders were undertaken regarding preventative health and 40 CHWs were observed making home visits by supervisors during the initial 6 months of fieldwork of the trial in eight villages in the Jinja District in Ug and a. The results were analyzed using the 5-SPICE framework . Observation of CHWs in the field identified a number of unanticipated issues including a general mistrust of the public health system by community members in areas that had an impact on maternal and newborn health . At the outset , CHWs often did not trust their own abilities and faced community expectations that they would provide curative rather than preventative care . Early community engagement , non-threatening home visits that enhanced friendship and supportive supervision improved the confidence of the CHWs and improved the trust and acceptance of the CHWs and the willingness of the community members to act on what was discussed The World Health Organization recommends four antenatal visits for pregnant women in developing countries . Cash transfers have been used to incentivize participation in health services . We examined whether modest cash transfers for participation in antenatal care would increase antenatal care attendance and delivery in a health facility in Kisoro , Ug and a. Twenty-three villages were r and omized into four groups : 1 ) no cash ; 2 ) 0.20 United States Dollars ( USD ) for each of four visits ; 3 ) 0.40 USD for a single first trimester visit only ; 4 ) 0.40 USD for each of four visits . Outcomes were three or more antenatal visits and delivery in a health facility . Chi-square , analysis of variance , and generalized estimating equation analyses were performed to detect differences in outcomes . Women in the 0.40 USD/visit group had higher odds of three or more antenatal visits than the control group ( OR 1.70 , 95 % CI : 1.13 - 2.57 ) . The odds of delivering in a health facility did not differ between groups . However , women with more antenatal visits had higher odds of delivering in a health facility ( OR 1.21 , 95 % CI : 1.03 - 1.42 ) . These findings are important in an area where maternal mortality is high , utilization of health services is low , and re sources are scarce Background Mobile phone technology is utilized for better delivery of health services worldwide . In low- and -middle income countries mobile phones are now ubiquitous . Thus leveraging mHealth applications in health sector is becoming popular rapidly in these countries . To assess the effectiveness of the Continuum of Care Services ( CCS ) mHealth platform in terms of strengthening the delivery of maternal and child health ( MCH ) services in a district in Bihar , a re source -poor state in India . Methods The CommCare mHealth platform was customized to CCS as one of the innovations under a project funded by the Bill and Melinda Gates Foundation to improve the maternal and newborn health services in Bihar . The intervention was rolled out in one project district in Bihar , during July 2012 . More than 550 frontline workers out of a total of 3000 including Accredited Social Health Activists , Anganwadi Workers , Auxilliary Nurse Midwives and Lady Health Supervisors were trained to use the mHealth platform . The service delivery components namely early registration of pregnant women , three antenatal visits , tetanus toxoid immunization of the mother , iron and folic acid tablet supply , institutional delivery , postnatal home visits and early initiation of breastfeeding were used as indicators for good quality services . The result ant coverage of these services in the implementation area was compared with rest of Bihar and previous year statistics of the same area . The time lag between delivery of a service and its record capture in the maternal and child tracking system ( MCTS ) data base was computed in a r and om sample of 16,000 beneficiaries . The coverage of services among marginalized and non-marginalized castes was compared to indicate equity of service delivery . Health system strengthening was viewed from the angle of coverage , quality , equity and efficiency of services . Results The implementation blocks had higher coverage of all the eight indicator services compared to rest of Bihar and the previous year . There was equity of services across castes for all the indicators . Timely capture of data was also ensured compared to paper-based reporting . Conclusion By virtue of its impact on quality , efficiency and equity of service delivery , health care manpower efficiency and governance , the mHealth inclusion at service provision level can be one of the potential strategy to strengthen the health system Objective To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements . Data sources Nairobi Urban Health and Demographic Surveillance System ( NUHDSS ) and two cross-sectional household surveys in Korogocho and Viw and ani informal settlements in 2004–05 and 2006–08 . Methods Odds of facility-based delivery were estimated before and after introduction of an output-based voucher . Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations , a non-voucher outpatient service . As part of NUHDSS , households in Korogocho and Viw and ani reported place of delivery and the presence of a skilled birth attendant ( 2003–10 ) and vaccination coverage ( 2003–09 ) . A detailed maternal and child health ( MCH ) tool was added to NUHDSS ( September 2006–10 ) . Prospect i ve enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006 . In addition to recording mother ’s place of delivery , NUHDSS-MCH recorded the use of the voucher . Findings There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch . Testing whether unrelated outpatient care also increased , a falsification exercise found no significant increase in immunizations for children 12–23 months of age in the same period . Although the proportion completing any antenatal care ( ANC ) visit remained above 95 % of all reported pregnancies and there was a significant increase in facility-based deliveries , the proportion of women completing 4 + ANC visits was significantly lower during the voucher programme . Conclusions A positive association was observed between vouchers and facility-based deliveries in Nairobi . Although there is a need for higher quality evidence and validation in future studies , this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved population PURPOSE We design ed and evaluated for feasibility an intervention-Yo Puedo-that addresses social network influences and socioeconomic opportunities in a neighborhood with substantial gang exposure and early childbearing . METHODS Yo Puedo combined conditional cash transfers for completion of educational and reproductive health wellness goals with life skills sessions , and targeted youth 16 - 21 years of age and same-aged members of their social network . We conducted a two-arm study with social networks r and omized to the intervention or a st and ard services control arm . We evaluated intervention uptake , adherence , and safety ; and assessed evidence of effects on behavioral outcomes associated with unintended pregnancy and sexually transmitted infection risk . RESULTS A total of 72 social networks composed of 162 youth enrolled , with 92 % retention over 6 months . Seventy-two percent of youth r and omized to the intervention participated in intervention activities : 53 % received at least one conditional cash transfer payment and 66 % came to at least one life skills session . We found no evidence that cash payments financed illicit or high-risk behavior . At 6 months , compared with controls , intervention participants had a lower odds of hanging out on the street frequently ( odds ratio [ OR ] , .54 ; p = .10 ) and a lower odds of reporting that their close friends had been incarcerated ( OR , .6 ; p = .12 ) . They reported less regular alcohol use ( OR , .54 ; p = .04 ) and a lower odds of having sex ( OR , .50 ; p = .04 ) . CONCLUSIONS The feasibility evaluation of Yo Puedo demonstrated its promise ; a larger evaluation of effects on pregnancy and sustained behavioral changes is warranted Background Only 39 % of deliveries in Pakistan are attended by skilled birth attendants , while Pakistan 's target for skilled birth attendance by 2015 is > 90 % . Methods A 12-month  maternal health voucher intervention was implemented in Dera Ghazi Khan City , located in Southern Punjab , Pakistan in 2009 . A pre-test/post-test non-experimental study was conducted to assess the impact of the intervention . Household interviews were conducted with r and omly selected women who delivered in 2008 ( the year prior to the voucher intervention ) , and with r and omly selected women who delivered in 2009 . A strong outreach model was used and voucher booklets valued at $ 50 , containing redeemable coupons for three antenatal care ( ANC ) visits , a postnatal care ( PNC ) visit and institutional delivery , were sold for $ 1.25 to low-income women targeted by project workers . Regression analysis was conducted to determine the impact of the voucher scheme on ANC , PNC , and institutional delivery . Marginal effects estimated from logistic regression analyses were used to assess the magnitude of the impact of the intervention . Results The women targeted by voucher outreach workers were poorer , less educated , and at higher parity .  After adjusting for these differences , women who delivered in 2009 and were sold voucher booklets were significantly more likely than women who delivered in 2008 to make at least three ANC visits , deliver in a health facility , and make a postnatal visit . Purchase of a voucher booklet was associated with a 22 percentage point increase in ANC use , a 22 percentage point increase in institutional delivery , and a 35 percentage point increase in PNC use . Conclusions A voucher intervention implemented for 12 months was associated with a substantial increase in institutional delivery . A substantial scale-up of maternal health vouchers that focus on institutional delivery is likely to bring Pakistan closer to achieving its 2015 target for institutional delivery Violence against women  is a major health and human rights problem yet there is little rigorous evidence as to how to reduce it . We take advantage of the r and omized roll-out of Ecuador 's  cash transfer program to mothers to investigate how an exogenous increase in a woman 's income affects domestic violence . We find that the effect of a cash transfer depends on a woman 's education and on her education relative to her partner 's . Our results show that for women with greater than primary school education a cash transfer significantly decreases psychological violence from her partner . For women with primary school education or less , however , the effect of a cash transfer depends on her education relative to her partner 's . Specifically , the cash transfer significantly increases emotional violence in households where the woman 's education is equal to or more than her partner 's Prenatal and delivery care are critical both for maternal and newborn health . Using the Demographic and Health Surveys ( DHS ) data for thirty-two low-income countries across Asia , sub-Saharan Africa and Latin America , and employing a two-level r and om-intercept model , this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual- , household- and community-level characteristics on a woman 's decision to give birth at a health facility or at home . The results show that  prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions , with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility . These variations are more pronounced for Sub-Saharan Africa . The influence of the number of prenatal visits , maternal age and education , parity level , and economic status of the  birthing women on the place of delivery is found to vary across the three geographical regions . The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households . The strong influence of number of visits , household wealth , education and regional poverty on the site of delivery setting suggests that policies aim ed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction , enhancing the status of women , and increasing primary and secondary school enrollment rate among girls
Results Data from 51 studies ( 15 more than previous review s ) and 22 cash transfer and voucher programmes  suggest that approaches tied to service use ( either via payment conditionalities or vouchers for selected services ) can increase use of antenatal care , use of a skilled attendant at birth and in the case of vouchers , postnatal care too .
The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care , and for vouchers for maternity care services and birth with a skilled birth attendant .
However , effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators .
There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes .
Background Cash transfers and vouchers are forms of ‘ dem and -side financing ’ that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years .