Determinants of hospital delivery in the context of conditional cash transfer for pregnant women in Dedza district of Malawi

Abstract

Introduction: A World Health Organization study conducted in 2016 revealed that hospital delivery was a key determinant in reduction of maternal morbidity and mortality. In Dedza District, Malawi, wide variation in proportion of hospital births exist among health facilities implementing Conditional Cash Transfers (CCT) for reimbursement of transport and hospital stay during childbirth to motivate women to deliver in health facility. Objectives: The study set out to identify socioeconomic and demographic characteristics determining hospital utilization in CCT context; determine proportion of hospital births attributed to CCT; explore perceptions of women towards intrapartum care in the context of CCT; and explain factors influencing home deliveries in the context of CCT. Methods: A cross-sectional survey was conducted at eight health facilities providing CCT to women for delivering in a health facility, with sample size of 369. Participants were selected using systematic sampling and a structured questionnaire was used to collect data from women attending Maternal Newborn and Child Health services. Three Focus Group Discussions (FGD) were conducted among CCT beneficiaries, none beneficiaries and those who delivered at home. Besides descriptive statistics, Chi-square testand multiple logistic binary regression was carried out. Results: A total 338 (91.6%) delivered at hospital. From univariate analysis, age at first pregnancy, number of antenatal care (ANC) visits and time of CCT awareness were associated with hospital delivery (Crude P < 0.05). In multivariate regression model, the odds of delivering at hospital for women who were aware of CCT program early was 11.97 (p<0.001) and those who attended four or more ANC visits was 2.74. Themes from FGDs reveal several barriers for hospital delivery, namely transport; hospital stay cost and attitude of care providers. Majority (86.5%) of women were satisfied with care in CCT facilities and were likely to return in future. Conclusion: Significant factors determining hospital delivery were number of antenatal visits and time of CCT program awareness. Cost of transport and hospital stay, previous hospital experience and attitude of health care providers are described by qualitative findings. Recommendations: Encouraging early CCT program awareness, incentivizing number of ANC visits, establishing mechanism allowing mother to travel to hospital without incurring personal cost and health system to focus on improving attitude of care providers are key measures for ensuring hospital delivery.