Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo
Abstract Background The maternal mortality ratio in the Democratic Republic of the Congo (DRC) remains among the highest globally. Despite ongoing investments in maternal health, there is only limited evidence on the effectiveness of health systems strengthening interventions in improving maternal h...
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2025-06-01
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| Series: | BMC Pregnancy and Childbirth |
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| Online Access: | https://doi.org/10.1186/s12884-025-07470-x |
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| author | David R. Hotchkiss Lauren S. Blum Leslie S. Craig Anicet Yemweni Janna Wisniewski Paul-Samson Lusamba-Dikassa |
| author_facet | David R. Hotchkiss Lauren S. Blum Leslie S. Craig Anicet Yemweni Janna Wisniewski Paul-Samson Lusamba-Dikassa |
| author_sort | David R. Hotchkiss |
| collection | DOAJ |
| description | Abstract Background The maternal mortality ratio in the Democratic Republic of the Congo (DRC) remains among the highest globally. Despite ongoing investments in maternal health, there is only limited evidence on the effectiveness of health systems strengthening interventions in improving maternal health service quality and utilization in fragile settings. The study assesses the impact of a large, complex health systems strengthening program on maternal health care utilization in the DRC. Methods A difference-in-differences approach was applied using population-based household survey data at baseline (2014) and endline (2017) from treatment and matched comparison areas in three provinces. The dependent variables were antenatal care (ANC) utilization and facility-based delivery. Additionally, qualitative data were analyzed to assess perceptions of maternal health care offered and identify barriers and strategies to improve care delivery. Results The health systems strengthening program significantly increased the probability of facility-based delivery, but had no significant impact on receiving at least four ANC visits. Qualitative findings suggest that uptake of ANC was constrained by travel distance, time burdens, limited community outreach, and cultural norms discouraging early ANC initiation. Conclusions Findings highlight the reliance on health centers and posts offering basic maternal services and limited accessibility of hospitals offering lifesaving comprehensive emergency obstetric care. This underscores the importance of formative research to inform interventions that align with social norms, address local barriers, and enhance the effectiveness of maternal health programs in fragile settings. |
| format | Article |
| id | doaj-art-c4212fca93b74ad9a50bfbb424b34dcc |
| institution | OA Journals |
| issn | 1471-2393 |
| language | English |
| publishDate | 2025-06-01 |
| publisher | BMC |
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| series | BMC Pregnancy and Childbirth |
| spelling | doaj-art-c4212fca93b74ad9a50bfbb424b34dcc2025-08-20T02:31:09ZengBMCBMC Pregnancy and Childbirth1471-23932025-06-0125111610.1186/s12884-025-07470-xAssessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the CongoDavid R. Hotchkiss0Lauren S. Blum1Leslie S. Craig2Anicet Yemweni3Janna Wisniewski4Paul-Samson Lusamba-Dikassa5Department of International Health & Sustainable Development, Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane UniversityDepartment of International Health & Sustainable Development, Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane UniversityDepartment of International Health & Sustainable Development, Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane UniversityConsultantDepartment of International Health & Sustainable Development, Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane UniversitySchool of Public Health, University of KinshasaAbstract Background The maternal mortality ratio in the Democratic Republic of the Congo (DRC) remains among the highest globally. Despite ongoing investments in maternal health, there is only limited evidence on the effectiveness of health systems strengthening interventions in improving maternal health service quality and utilization in fragile settings. The study assesses the impact of a large, complex health systems strengthening program on maternal health care utilization in the DRC. Methods A difference-in-differences approach was applied using population-based household survey data at baseline (2014) and endline (2017) from treatment and matched comparison areas in three provinces. The dependent variables were antenatal care (ANC) utilization and facility-based delivery. Additionally, qualitative data were analyzed to assess perceptions of maternal health care offered and identify barriers and strategies to improve care delivery. Results The health systems strengthening program significantly increased the probability of facility-based delivery, but had no significant impact on receiving at least four ANC visits. Qualitative findings suggest that uptake of ANC was constrained by travel distance, time burdens, limited community outreach, and cultural norms discouraging early ANC initiation. Conclusions Findings highlight the reliance on health centers and posts offering basic maternal services and limited accessibility of hospitals offering lifesaving comprehensive emergency obstetric care. This underscores the importance of formative research to inform interventions that align with social norms, address local barriers, and enhance the effectiveness of maternal health programs in fragile settings.https://doi.org/10.1186/s12884-025-07470-xMaternal health careDemocratic Republic of the CongoImpact evaluationFragile states |
| spellingShingle | David R. Hotchkiss Lauren S. Blum Leslie S. Craig Anicet Yemweni Janna Wisniewski Paul-Samson Lusamba-Dikassa Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo BMC Pregnancy and Childbirth Maternal health care Democratic Republic of the Congo Impact evaluation Fragile states |
| title | Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo |
| title_full | Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo |
| title_fullStr | Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo |
| title_full_unstemmed | Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo |
| title_short | Assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo |
| title_sort | assessing the impact of complex health systems strengthening programs on maternal health care utilization in fragile and conflict affected states evidence from the democratic republic of the congo |
| topic | Maternal health care Democratic Republic of the Congo Impact evaluation Fragile states |
| url | https://doi.org/10.1186/s12884-025-07470-x |
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