ISF Faculty Dr. Amm Quamruzzaman Published in Top Journal

Dr. Amm Quamruzzaman co-authored a paper with world-renowned researchers
and published it in a top journal PLOS MEDICINE (impact factor 11.61). The study
investigated “Health care services use, stillbirth, and neonatal and infant survival
following implementation of the Maternal Health Voucher Scheme in Bangladesh”
(the paper is available here https://doi.org/10.1371/journal.pmed.1004022).

Why was this study done?
 Most women in Bangladesh do not receive essential maternal health
services, with especially low rates of coverage for poorer households in
rural areas.
 Starting in 2006 to 2007, the Government of Bangladesh implemented the
Maternal Health Voucher Scheme (MHVS) to increase demand for and
equitable use of maternal health services.
 Prior studies suggest that access to the MHVS, consistent with the broader
literature on maternal voucher programs, was associated with greater use
of priority maternal health services.
 However, it is unclear if short-term increases in maternal health service use
are sustained over time and evidence for impacts on perinatal, infant, and
maternal health outcomes, including mortality, is inconclusive.
What did the researchers do and find?
 They linked details on the rollout of the MHVS across subdistricts (i.e.,
upazilas) to information on pregnancies and live births reported by women
surveyed as part of the Bangladesh Demographic and Health Surveys
between 2000 to 2016.
 They used a difference-in-differences design to evaluate the association
between upazila-level access to the MHVS and maternal health services
utilization, stillbirth, and neonatal and infant mortality.
 They observed increases in the use of maternal health services, particularly
on the probability of delivering in a health facility, that materialized 2 or
more years after program implementation.
 However, improvements in stillbirths, neonatal, and infant mortality were
not demonstrated, raising important questions about program
implementation.

What do these findings mean?
 Potential explanations of the gap between increased services and improved
outcomes include that the program may not have been targeted to reach
the highest risk mothers, that implementation may have failed to increase
use by mothers at highest risk, that in the absence of simultaneous supply-
side interventions quality of services provided may have declined with
increased numbers of patients or been inadequate, and that hospital births
are associated with higher rates of bottle feeding in Bangladesh and lower
rates of protective breastfeeding.
 Additionally, it is possible that small but consequential effects in health
outcomes could not be discerned due to imprecision in these estimates.
 Further research is needed to examine why increased services have not yet
translated into improved health outcomes as it pertains to the MHVS and
other voucher programs.
 This could include cluster randomized experimental designs with the
potential to address the main limitations of this study, specifically the
potential for observational studies to conflate the impact of a voucher
program with the effects of other population-level health and social
interventions.