title: Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya.
abstract: 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.
  
  
  METHODS
  Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani 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 Viwandani 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). Prospective 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.
  
  
  RESULTS
  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 populations.
authors.affiliation: Population Council, Ralph Bunche Rd, General Accident House, PO Box 17643-00500, Nairobi, Kenya. bbellows@popcouncil.org
authors.forename: Ben
authors.initials: B
authors.lastname: Bellows
authors.forename: Catherine
authors.initials: C
authors.lastname: Kyobutungi
authors.forename: Martin Kavao
authors.initials: MK
authors.lastname: Mutua
authors.forename: Charlotte
authors.initials: C
authors.lastname: Warren
authors.forename: Alex
authors.initials: A
authors.lastname: Ezeh
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D005380:Financing, Government / Q000458:organization & administration; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008427:Maternal Health Services / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data*; D008875:Middle Aged; D010298:Parity; D011247:Pregnancy; D012959:Socioeconomic Factors; D055815:Young Adult