Demand-side financing in the form of baby packages in Northern Mozambique: Results from an observational study

Background The Maternal Mortality Ratio in Mozambique has stagnated at 405 deaths per 100,000 live births with virtually no progress over the last 15 years. Low Institutional Birth Rates (IBRs) levelling around 50% in many rural areas constitute one of the contributing reasons. Demand-side financing has successfully increased usage of maternal health services in other countries, but little information exists on in-kind incentives in rural Africa. The objective was to test the impact on Institutional Birth Rates of giving a USD 5.50 baby package incentive to every woman who came to give birth in a health centre in a rural, poor district of Cabo Delgado, Mozambique. Methods and findings The intervention was implemented in one district in 2010 with the remaining 15 districts serving as controls. The total population in the 16 districts in 2006 was just under 1.5 million people. IBRs were observed from 2006 to 2013 (53 months before and 55 months after the intervention began). The non-intervention districts showed a slight increase, from a mean IBR of 0.39 (SD = 0.10) in 2006 to 0.67 (SD = 0.13) in 2014. The intervention district had a dramatic increase in IBRs within six months of the start of the intervention in 2010, which was sustained until the end of the study. Adjusting for the background increase and for confounders, including health facilities and health personnel per district, and taking clustering in districts into account, the estimated rate ratio of institutional births in the intervention district was 1.80 (95% CI 1.72, 1.89 p<0.001). Conclusion Women were almost twice as likely to have an institutional birth following the introduction of the baby package.