When Phyllis arrived at the clinic to deliver her baby, she didn't expect that they would both shortly be at death's door. Neither did her doctors. As a recipient of a "safe motherhood voucher" Phyllis had received all her antenatal checks and had been prepared for a natural birth. When she settled in at the Limuru Nursing Home, a clinic on the outskirts of Nairobi, Kenya, Phyllis unexpectedly presented with cephalopelvic disproportion, a situation in which the delivery is obstructed because of the baby's size in relation to the size of the mother's pelvis. Nothing in her prior tests had indicated that she would experience complications, and the medical staff had to operate immediately, performing an emergency Caesarean section.
Seventy-six percent of Kenya's poorest women do not give birth in health-care facilities, and the maternal mortality rate in the country is the same as it was eight years ago. Phyllis and her baby survived, but if she hadn't been a recipient of the safe motherhood voucher, she would have delivered at home, and it is very likely that the baby would have died, and she may have lost her life, as well.
"If she was to give birth at home, it would have been impossible," said Dr. Kaburu, the anesthesiologist during Phyllis' delivery. "She would have landed finally at a hospital probably with the baby dead."
Phyllis' delivery and Dr. Kaburu's testimony can be seen firsthand in this webisode about complications that arise during delivery, and the role the vouchers play in helping combat maternal mortality. The webisode is the third in a series and was part of a 30-minute documentary called Kadi: Saving Mothers and Babies, One Voucher at a Time.
Vouchers, similar to coupons, are sold at a highly subsidized rate to poor pregnant women in rural and urban areas and provide a package of services enabling a woman to safely give birth at a participating clinic. Unlike coupons, however, they aren't available to everybody and often serve a targeted community. The project is made possible by the government of Kenya, with support from its German development partners BMZ (Federal Ministry for Economic Cooperation and Development) and KfW Banking Group, as a Vision 2030 flagship program, launched in 2006, that utilizes public and private facilities. RH (Reproductive Health) Vouchers is a Bill & Melinda Gates Foundation-funded Population Council project that evaluates the efficacy of these voucher programs. In addition to Kenya, RH Vouchers evaluates voucher programs in Tanzania, Uganda, Bangladesh, and Cambodia.
"Poor mothers face many barriers to health care," said Ben Bellows, Population Council Associate and RH Vouchers Project Manager. "Women may be unfamiliar with delivering in a facility. Some poor mothers may know only a few in their extended family or social network who have delivered before at facility. They may have a limited ability to pay for a facility delivery."
Globally, 350,000 women die every year from pregnancy or delivery related complications, but these aren't the only casualties. According to the United Nations Population Fund (UNFPA), "Maternal mortality statistics ... are only the tip of the iceberg. For every woman who dies, some twenty others face serious or long-lasting consequences." This means that 7 million women each year will suffer grave consequences from the simple act of giving birth.
"The voucher should incentivize earlier treatment seeking," Bellows said. "So in the event of a complication, mothers should already be at the facility rather than attempt to deliver at home only to be rushed to facility in the event of a complication."
Sylvia Macharia, a nurse at Jahmii Medical Center in Korogocho, a Nairobi slum, and one of the sites where the vouchers are distributed, said that working in maternal health is an uphill battle, but that the vouchers make a huge difference.
"The women don't know what might happen. They are always in danger because they don't know what to expect -- and at home there is no trained midwife or doctor," she said.
Macharia also said that the vouchers give the women confidence to come to the hospital, because they can redeem the voucher and are less worried about being mistreated.
"Maternal health is grossly underfunded," said John Townsend, Vice President and Director of the Population Council's Reproductive Health Program, "so there is no reason we should believe that quality assurance strategies which would fall within the same system would be much better."
As well as providing a safety net, vouchers aim to provide high-quality care. Poor and disenfranchised women often get second-rate care, but the vouchers are changing this.
"At the facility, overworked and underpaid providers may not focus on giving the best possible care to poor mothers. Providers may be verbally abusive," said Bellows. "These are some of the issues that vouchers can ... address as they give patients the financial means to overcome price constraints and give providers a strong incentive to treat the client well."
The voucher program uses the existing infrastructure and accredits various clinics; this means clients have a variety of options for where they can redeem their vouchers, in turn creating competition between service providers, pressuring them all to increase their quality in order to attract more women, thus shifting the balance of power to the customer.
However, there are some challenges in implementing vouchers and having a system based on the resources that are already available.
Those who most need reproductive health care are those living below the poverty line in urban areas, typically living in slums, or those in remote rural areas, who often do not have any access to care at all. A challenge the programs face is getting care to rural areas. While urban areas may have both public and private providers, rural areas may only have public services. Most reproductive health programs cannot change the short-term structure of care, and so they can only hope that there is a high enough volume of services that would entice providers to move to rural areas, which has proven difficult thus far.
"The highest-quality providers are not willing to live in rural areas. That's a challenge we recognize in many countries," Townsend said. "One of the ways people are thinking about that is to either use a strategy like using qualified paramedical staff to provide certain types of medical care, midwives instead of physicians for delivery of births, or using auxiliary nurses for provision of clinical family planning methods with the provided appropriate training."
"In Kenya, the high out-of-pocket cost of care is addressed by the vouchers," Bellows said. "Vouchers, however, have their limitations. In deep rural areas without facilities, travel and transport are still required to go to facilities, and the voucher does not directly address this distance issue."
In the evaluation of these programs, Townsend said it is a matter of identifying what works, and finding the most effective strategies to tackle the problem.
In the government of Kenya's June-2011-to-June-2012 fiscal year, the vouchers program aims to distribute 39,000 safe motherhood vouchers. This is 3,000 more than the previous fiscal year and illustrates how the vouchers are gaining traction as a reproductive health financing mechanism in the country. Currently, the program has 88 contracted public, private, and nonprofit providers and operates in four districts and two slums. Phyllis is just one of the 9 million women in Kenya who are of reproductive age, and only one of the 20 percent of the poorest women who manage to deliver in a hospital. By taking care of the financing aspect, vouchers are paving the way for poor women to receive more effective reproductive health.
"There are as many ways to address this as there are creative people," Townsend said, "but essentially it's around doing things at a scale that will make a difference to large numbers of people."
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