Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor. Income Transfers and Maternal Health: Evidence from a National Randomized Social Cash Transfer Program in Zambia. 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 The impact of Mexico's conditional cash transfer programme, Oportunidades, on birthweight. Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme. Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades Conditional Cash Transfers And Health Of Low-Income Families In The US: Evaluating The Family Rewards Experiment. Assessing the population-level impact of vouchers on access to health facility delivery for women in Kenya. Conditional cash transfers to improve education and health: an ex ante evaluation of Red de Protección Social, Nicaragua. Cash for Women’s Empowerment? A Mixed-Methods Evaluation of the Government of Zambia’s Child Grant Program The Government of Kenya's Cash Transfer Program Reduces the Risk of Sexual Debut among Young People Age 15-25 Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan The Short-Term Impacts of a Schooling Conditional Cash Transfer Program on the Sexual Behavior of Young Women Cash value of voucher reinforcers in pregnant drug-dependent women. Cash Transfers to Increase Antenatal Care Utilization in Kisoro, Uganda: A Pilot Study.
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 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 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 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 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 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 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 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 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 Although available evidence indicates that vouchers improve service utilization among the target population s , we do not know whether increased utilization results from improved access ( new clients who would not have used services without the voucher ) or from shifting clients from non-accredited to contracted service providers . This paper examines whether the  safe motherhood voucher program in Kenya is associated with improved access to health facility delivery using information on births within two years preceding the survey in voucher and comparison sites . Data were collected in 2010 - 2011 and in 2012 among 2933 and 3094 women aged 15 - 49 years reporting 962 and 1494 births within two years before the respective surveys . Analysis entails cross-tabulations and estimation of multilevel r and om-intercept logit models . The results show that the proportion of births occurring at home declined by more than 10 percentage points while the proportion of births delivered in health facilities increased by a similar margin over time in voucher sites . The increase in facility-based births occurred in both public and private health facilities . There was also a significant increase in the likelihood of facility-based delivery ( odds ratios [ OR ] : 2.04 ; 95 % confidence interval [ CI ] : 1.40 - 2.98 in the 2006 voucher arm ; OR : 1.72 ; 95 % CI : 1.22 - 2.43 in the 2010 - 2011 voucher arm ) in voucher sites over time . In contrast , there were no significant changes in the likelihood of facility-based delivery in the comparison arm over time . These findings suggest that the voucher program contributed to improved access to institutional delivery by shifting births from home to health facilities . However , available evidence from qualitative data shows that some women who purchased the vouchers did not use them because of high transportation costs to accredited facilities . The implication is that substantial improvements in service uptake could be achieved if the program subsidized transportation costs as well Using baseline data from a r and omized experiment , this article extends and tests in the context of health , the feasibility of a recently proposed reduced form approach to ex ante evaluations of social programs with an application to a  conditional cash transfer program in Nicaragua . It uses a behavioural model to estimate the impact on preventive care utilization outcomes for children younger than 3 years . It vali date s the model with the results of the experiment and then simulates two alternate policy scenarios . The model performs well in predicting the health related outcomes and shows different results for the two sets of policy scenarios . In addition , simulations are also carried out for the school component of the cash transfer program Summary . — The empowerment of women , broadly defined , is an often-cited objective and benefit of social cash transfer programs in developing countries . Despite the promise and potential of cash transfers to empower women , the evidence supporting this outcome is mixed . In addition , there is little evidence from programs at scale in sub-Saharan Africa . We conducted a mixed- methods evaluation of the Government of Zambia ’s Child Grant Program , a poverty-targeted , unconditional transfer given to mothers or primary caregivers of young children aged zero to five . The quantitative component was a four-year longitudinal clustered-r and omized control trial in three rural districts , and the qualitative component was a one-time data collection involving in-depth interviews with women and their partners stratified on marital status and program participation . Our study found that women in beneficiary households were making more sole or joint decisions ( across five out of nine domains ) ; however , impacts translated into relatively modest increases in the number of decision domains a woman is involved in , on average by 0.34 ( or a 6 % increase over a baseline mean of 5.3 ) . Qualitatively , we found that changes in intrahousehold relationships were limited by entrenched gender norms , which indicate men as heads of household and primary decision makers . However , women ’s narratives showed the transfer increased financial empowerment as they were able to retain control over transfers for household investment and savings for emergencies . We highlight method ological challenges in using intrahousehold decision making as the primary indicator to measure empowerment . Results show potential for unconditional cash transfer programs to improve the financial and intrahousehold status of female beneficiaries , however it is likely additional design components are need for transformational change The aim of this study is to assess whether the Government of Kenya 's Cash Transfer for Orphans and Vulnerable Children ( Kenya CT-OVC ) can reduce the risk of HIV among young people by postponing sexual debut . The program provides an unconditional transfer of US$ 20 per month directly to the main caregiver in the household . An evaluation of the program was implemented in 2007–2009 in seven districts . Fourteen Locations were r and omly assigned to receive the program and fourteen were assigned to a control arm . A sample of households was enrolled in the evaluation in 2007 . We revisited these households in 2011 and collected information on sexual activity among individuals between 15–25 years of age . We used logistic regression , adjusted for the respondent 's age , sex and relationship to caregiver , the age , sex and schooling of the caregiver and whether or not the household lived in Nairobi at baseline , to compare rates of sexual debut among young people living in program households with those living in control households who had not yet entered the program . Our results , adjusted for these covariates , show that the program reduced the odds of sexual debut by 31 percent . There were no statistically significant effects on secondary outcomes of behavioral risk such as condom use , number of partners and transactional sex . Since the CT-OVC provides cash to the caregiver and not to the child , and there are no explicit conditions associated with receipt , these impacts are indirect , and may have been achieved by keeping young people in school . Our results suggest that large-scale national social cash transfer programs with poverty alleviation objectives may have potential positive spillover benefits in terms of reducing HIV risk among young people in Eastern and Southern Africa 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 Recent evidence suggests that conditional cash transfer programs for schooling are effective in raising school enrollment and attendance . However , there is also reason to believe that such programs can affect other outcomes , such as the sexual behavior of their young beneficiaries .  Zomba Cash Transfer Program is a r and omized , ongoing conditional cash transfer intervention targeting young women in Malawi that provides incentives ( in the form of school fees and cash transfers ) to current schoolgirls and recent dropouts to stay in or return to school . An average offer of US$ 10/month conditional on satisfactory school attendance – plus direct payment of secondary school fees – led to significant declines in early marriage , teenage pregnancy , and self-reported sexual activity among program beneficiaries after just one year of program implementation . For program beneficiaries who were out of school at baseline , the probability of getting married and becoming pregnant declined by more than 40 percent and 30 percent , respectively . In addition , the incidence of the onset of sexual activity was 38 percent lower among all program beneficiaries than the control group . Overall , these results suggest that conditional cash transfer programs not only serve as useful tools for improving school attendance , but may also reduce sexual activity , teen pregnancy , and early marriage This study examined the relative reinforcing potency of vouchers and cash in drug-dependent pregnant women ( N = 48 ) across  voucher values ( US 10 dollars , US 50 dollars , and US 100 dollars ) by use of a series of choices to underst and how exchange-delay features of voucher reinforcers influence their reinforcing potency compared with cash . The study also examined a no delay vs. 2-day delay of the cash alternative . Generally , cash was selected at 80%-90 % of voucher face values . Vouchers were also discounted less when a 2-day delay was imposed on the cash option compared to the immediately available cash . These results suggest that voucher discounting does occur among patients in drug treatment . However , vouchers retain 80%-90 % of their cash value and thus remain relatively potent reinforcers 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
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 .