Kenya introduced free maternal healthcare a decade ago – research shows it has been a success and saved lives

Kenya has seen an overall improvement in maternal and newborn health outcomes. Credits: Belen B Massieu/Shutterstock

Maternal and newborn deaths are a major public health problem in Kenya. In 2020, the maternal mortality rate was 530 deaths per 100,000 live births. This is much higher than the global average of 223 maternal deaths per 100,000 live births. The number of babies dying in the first month of life (neonatal death) is also higher than the global average. Kenya’s neonatal mortality rate is 21 deaths per 1,000 live births. The global rate is 18 deaths per 1,000.

Most of these deaths could be prevented if women receive maternal medical care. This includes care during pregnancy and expert counselors during childbirth. The World Health Organization has recognized that user fees are a major barrier to care like this.

In order to provide more women with health care during pregnancy and childbirth, Kenya introduced free maternity care in 2013. The program, known as Linda mama, consists of a package of benefits. Benefits include prenatal care, assisted delivery and outpatient care for babies up to nine months old. This program is a step towards universal health insurance for Kenya.

Pregnant women can access these services in a range of healthcare facilities, including those run by the government, faith-based organizations, non-governmental organizations, or private providers. Women with alternative health insurance are excluded from the service.

In our recent study, published in The European Journal of Health Economics, we wanted to show the impact of this policy. We focused on: neonatal deaths; skilled midwives; and children born with a low birth weight. We also presented the cost-benefit analysis of the free maternity policy. Estimating the contribution of the policy is important to guide its sustainable financing through the budget.

We found an overall improvement in maternal and newborn health outcomes. More women – especially poor women – now have access to maternal care. And the net benefits of the policy far outweighed the costs. Further investment in the free maternity policy could potentially prevent even more maternal and neonatal deaths.

Our study

We used data from Kenya’s demographic health survey to evaluate the impact of the free maternity care policy on a number of key indicators. We compared the rates before and after the start of the policy. The indicators we focused on were:

  • early neonatal death (death within the first seven days of life): Our study showed that the rate of birth resulting in early neonatal death was significantly reduced by 21 percentage points after the implementation of the policy from 22 deaths per 1,000 live births in the period before the policy was implemented to approximately 17.4 deaths per 1,000 live births after the policy was implemented. This decline shows that investments in public health initiatives (such as free maternity care and possibly free primary care), better access to water and sanitation are paying off.

  • neonatal mortality (death within the first 28 days of life): The chances of birth resulting in neonatal death were significantly reduced by 20 percentage points. As with early neonatal mortality, this contributed to the reduction from 22 deaths per 1,000 live births before policy implementation to approximately 17.6 deaths per 1,000 live births after policy implementation.

  • skilled birth guidance: Our research shows that the probability of skilled birth attendance increased by 16 percentage points. This was not statistically significant, because while part of the improvements could be due to the free maternity policy, the rest of the effect may be attributed to other mechanisms, such as quality of care (neonatal and maternal), availability of antenatal care and identification of possible complications earlier in pregnancy, which should be investigated in the future. While not significant, it also plausibly demonstrates that many women who were unable to access maternal care prior to the policy would be able to access it as a result. In the five years before the free maternity policy, 61.8% of all deliveries were attended by an experienced health professional. Currently, 89.3% of all births now have skilled birth support services.

  • low birth weight: Our research shows that the chance of having a child with a low weight at birth increased by 4.4 percentage points. This was also not statistically significant. The prevalence of low birth weight newborns before the free maternity policy was 6.89%.

We also performed a limited cost-benefit analysis to assess the net social benefits of the free maternity policy. We used the most appropriate cost-effectiveness indicators (cost versus effectiveness) and compared the annual costs of policy implementation with the average annual per avoided neonatal death.

Since the policy resulted in an average of 4,015 fewer neonatal deaths after implementation, the cost-benefit ratio of the policy was 21.22. The net benefits of the policy were 21 times higher than the cost. This shows that the free maternity policy is associated with a high return to the country. Policymakers should look at ways to further expand free maternity policies and finance them sustainably for even better outcomes.

Way ahead

The reduction in early neonatal and neonatal mortality and increase in skilled deliveries caused by the policy can be sustained if more women are encouraged to give birth in health centers. This can be done by promoting awareness of the policy and the fringe benefits package.

The government must address health system challenges that could hinder the positive impact of the policy. The challenges include a shortage of health workers, an increased workload and a shortage of medicines.

In addition, more institutions must be accredited to offer free maternity care. This addresses the problem of people having to travel long distances to access free maternity benefits.

More information:
Boniface Oyugi et al, Does Free Maternity Policy Work in Kenya? Impact and cost-benefit assessment based on demographic health survey data, The European Journal of Health Economics (2023). DOI: 10.1007/s10198-023-01575-w

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Kenya introduced free maternal healthcare a decade ago – research shows it has been a success and saved lives

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