The Impact of a Mobile Money–Based Intervention on Maternal and Neonatal Health Outcomes in Madagascar: Cluster-Randomized Controlled Trial (Preprint)

<sec> <title>BACKGROUND</title> Financial barriers to accessing obstetric care persist in many low-resource settings. With increasing use of mobile phones, mobile money services appear as a promising tool to address this concern. Maternal health care is particularly suitable for a savings program using mobile money due to the predictable timing and costs of delivery. The mobile money–based Mobile Maternal Health Wallet (MMHW) intervention aimed to ease the burden of out-of-pocket expenses related to maternal health care by providing an accessible savings tool. </sec> <sec> <title>OBJECTIVE</title> This study aimed to assess the impact of the MMHW on maternal and neonatal health outcomes. </sec> <sec> <title>METHODS</title> We used a stratified cluster-randomized trial to assess the impact of the MMHW on maternal and neonatal health outcomes in the Analamanga region of Madagascar. All 63 eligible public sector primary care health facilities (&lt;i&gt;Centres de Santé de Base&lt;/i&gt; [CSBs]) within 6 strata were randomized to either receive the intervention or not. We estimated intention-to-treat effects and contamination-adjusted effects following an instrumental variable approach. The primary outcomes included (1) delivery at a health facility, (2) antenatal care visits, and (3) total health care expenditure. Between March 2022 and December 2022, a total of 6483 women who had been pregnant between July 2020 and December 2021 were surveyed. </sec> <sec> <title>RESULTS</title> Among women in catchment areas of treated CSBs, 38.79% (1297/3344) had heard of the MMHW, and 37.42% (485/1296) of them registered for the tool. There was considerable variation in uptake across treated CSBs. Descriptively, women in the catchment areas of treated CSBs were more likely to deliver in a facility and had more antenatal care visits and higher total health expenditures compared to women in control CSB catchment areas in the intention-to-treat and contamination-adjusted analyses. However, none of the effects were statistically significant. </sec> <sec> <title>CONCLUSIONS</title> While this study did not identify a statistically significant impact, the estimated contamination-adjusted effects suggest that the MMHW has potential to improve access to maternal care for women who are receptive to such a mobile money–based savings tool. Estimated population-level effects were much smaller, and this study was underpowered to detect such effects due to lower-than-anticipated uptake of the intervention. </sec> <sec> <title>CLINICALTRIAL</title> German Clinical Trials Register DRKS00014928; https://www.drks.de/search/de/trial/DRKS00014928 </sec> <sec> <title>INTERNATIONAL REGISTERED REPORT</title> RR2-10.1186/s13063-021-05694-8 </sec>