Daniella Brals, Sunday A Aderibigbe, Ferdinand W Wit, Johannes C M van Ophem, Marijn van der List, Gordon K Osagbemi, Marleen E Hendriks, Tanimola M Akande, Michael Boele van Hensbroek, and Constance Schultsz
Background: Access to quality obstetric care is considered essential to reducing maternal and
new-born mortality. We evaluated the effect of the introduction of a multifaceted voluntary health
insurance programme on hospital deliveries in rural Nigeria.
Methods: We used an interrupted time-series design, including a control group. The intervention
consisted of providing voluntary health insurance covering primary and secondary healthcare,
including antenatal and obstetric care, combined with improving the quality of healthcare facilities.
We compared changes in hospital deliveries from 1 May 2005 to 30 April 2013 between the programme
area and control area in a difference-in-differences analysis with multiple time periods, adjusting
for observed confounders. Data were collected through household surveys. Eligible households (n
¼ 1500) were selected from a stratified probability sample of enumeration areas. All deliveries during
the 4-year baseline period (n ¼ 460) and 4-year follow-up period (n ¼ 380) were included.
Findings: Insurance coverage increased from 0% before the insurance was introduced to 70.2%
in April 2013 in the programme area. In the control area insurance coverage remained 0% between
May 2005 and April 2013. Although hospital deliveries followed a common stable trend over the 4
pre-programme years (P ¼ 0.89), the increase in hospital deliveries during the 4-year follow-up
period in the programme area was 29.3 percentage points (95% CI: 16.1 to 42.6; P < 0.001) greater
than the change in the control area (intention-to-treat impact), corresponding to a relative increase
in hospital deliveries of 62%. Women who did not enroll in health insurance but who could make
use of the upgraded care delivered significantly more often in a hospital during the follow-up
period than women living in the control area (P ¼ 0.04).
Conclusions: Voluntary health insurance combined with quality healthcare services is highly effective
in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for
insured and uninsured women in the programme area.
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